motor vehicle release authorization

IMPORTANT: ALL (3) Steps must be completed below.

DIRECTION TO PAY LEGALLY ENTITLED CARRIER OR GARAGEMAN OF THE LOADING, UNLOADING AND STORAGE OF A DAMAGED VEHICLE UNDER MGL c.90 §34(O)

Step 1: Fill Out ALL Appropriate Fields Below

Name:

Address:

City:

Zip Code:

Phone Number:

Insurance Company:

Vehicle Year

Vehicle Model

Vehicle Make

Vehicle Color

Vehicle Plate Number:

V.I.N. Number:

I AUTHORIZED CJ'S TOWING UNLIMITED INC. TO RELEASE MY VEHICLE TO THE INSURANCE COMPANY LISTED ABOVE EFFECTIVE FROM THIS DATE.

Owners Authorization

MY INSURANCE COMPANY OR RESPONSIBLE COMPANY TO INSPECT/APPRAISE MY VEHICLE

Owners Authorization

MY INSURANCE COMPANY OR RESPONSIBLE COMPANY TO REMOVE MY VEHICLE FROM CJ'S

Owners Authorization

I HAVE REMOVED ALL PERSONAL BELONGINGS

Owners Authorization

Todays Date:

Electronic Signature:

Legal

This information above is true and correct to the best of my knowledge. This electronic signature is valid and is the exact name on my State Issued ID or Drivers License. I agree and I am aware that the IP address on submission of this form will be documented by CJ'sTowing & Recovery and may be used in a court of law in leiu of a handwritten signature.

Step 2: After Submit Form, Upload ID or Drivers License

UNDER MGL C.255 §39A, IF THE REGISTERED OWNER OR PERSONS IN CONTROL OF THE MOTOR VEHICLE ASSENTS TO THE CONTINUED CONSENSUAL STORAGE OF SUCH MOTOR VEHICLE, CJ’S TOWING UNLIMITED INC. SHALL CONTINUE TO HOLD SAID MOTOR VEHICLE IN STORAGE AT $85.00 PER 24 HOUR PERIOD THEREAFTER AND SHALL HAVE A LIEN THEREON, AS PROVIDED IN MGL C.255 §25. IF THE REGISTERED OWNER OR PERSONS IN CONTROL OF THIS MOTOR VEHICLE FAILS TO SIGN THIS RELEASE NOTICE THE MOTOR VEHICLE SHALL CONTINUE TO BE STORED AT THE PREVAILING RATES UNDER MGL C.255 §39A.

I AGREE TO NOTIFY THE ABOVE INSURANCE COMPANY, IN WRITING, IF ANY PAYMENTS FOR TOWING & STORAGE FOR THE ABOVE REFERENCED CLAIM ARE MADE. THEY ARE TO BE MADE TO CJ’S TOWING INC. WITH THIS SIGNED DIRECTION TO PAY FORM