ERIE INSURANCE REPAIR AUTHORIZATION FORM

A Member Company of Erie Insurance has assigned

Vehicle Owner/Lessee:
InsuredClaimant

The vehicle involved in the loss/accident is:

Erie Insurance Work Authorization

The Owners/Lessees have selected:

Axelrod Collision Center
4850 Brookpark Rd,
Cleveland OH, 44134

216-325-5600

to make repairs to the above vehicle.

BY CLICKING SUBMIT I AM DIGITALLY SIGNING THIS FORM AND GIVING AUTHORIZATION AND POWER OF ATTORNEY TO AXELROD COLLISION AS STATED FORTH IN THIS DOCUMENT.