Statement of Satisfaction and Completion | Authorization to Pay | Quality Assurance Form | Back to Quality Assurance Page Sample Authorization to Pay Form Insured:________________________________________ Claim Number:_________________________________________ To: ABC Insurance Company I understand this AUTHORIZATION TO PAY extends solely for the repair expenses covered by ABC Insurance Company's insurance policy and completed as a result of the loss occurring on [date]. My deductible and additional work for repairs not covered is solely my responsibility. I hereby authorize payment on my behalf in the above referenced claim to the contractor(s) below. To:      1st Action Services                 $__________________ To:                                                 $__________________ To:                                                 $__________________ By Insured:                                                            Dated:                                                            Our Promise | What We Do | What to Expect | Photo Gallery | Q.A. Program | Helpful Resources | Contact Us | Home 1st Action Services Copyright © 2000. All rights reserved. Developed by Compass Marketing Group