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1950 Winchester Ave
Reedsport OR 97467
Ph# 541.271.3019
Fax# 541.271.4830

AUTHORIZATION AND DIRECTION TO PAY

LIABILITY INSURANCE CLAIM

Customer Information

Address

Vehicle Description

Insurance

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I authorize and direct the Insurance Provider mentioned above to pay Mast Bros Enterprises Inc for labor and services o my behalf concerning this Insurance claim.
Vehicle Release*
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