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| Document Name | Direction To Pay |
| Form Size | 1 pages |
| Can I Fill It Out? | No |
| # of Fields | 0 |
| Other names | direction to pay form, repair authorization and direction to pay, direction to pay form body shop |
AUTHORIZATION AND DIRECTION TO DISCLOSE POLICY
The undersigned, being all of the policyholders of the above identified policy or policies, do hereby authorize and direct The Commerce Insurance Company, through its employees and/or authorized representatives, to disclose information about the above identified policy or policies, including without limitation personally identifiable information of the undersigned, to the individuals or entities specified below. In so doing, the undersigned hereby expressly waive(s) all rights under any federal and/or state statutes or regulations regarding the privacy of personally identifiable information relating to the identified policy or policies and agree to indemnify and hold harmless The Commerce Insurance Company with respect to any such information disclosed in accordance with this authorization. This written authorization to release information shall remain effective until revoked in writing signed by the undersigned and delivered to The Commerce Insurance Company.
In accordance with the foregoing, information regarding the above identified policy or policies should be disclosed to the following:
