Total Liberty

Care Program

Direction of Payment

Claim Number ___________________________________________________________

Insured Name ___________________________________________________________

Claimant Name ________________________________________________________________

(if different from Insured)

I authorize Liberty Mutual Insurance Company to make payment, on my behalf, directly to

Repairer Name __________CAR Collision Center LLC _______________________________

Repairer Address ______________7967 Twist Lane ____________________________________

City, State, Zip ____________ Springfield, Va 22153 _________________________________

Tax ID Number ________________41-2235434______________________________________

For any authorized repairs, and for which I am entitled to be compensated, resulting from the

Above captioned claim.

Printed Name _____________________________________Date ______________________

Signature ________________________________________________________________

Liberty Mutual Insurance • Personal Market Claims