[vc_row][vc_column] Customer Sign In Information 1First Name & Address Your Full Name Street Address 2Email & Phone Email Address Phone Number Please leave this field empty. 3Insurance Company Please leave this field empty. Insurance Company Name:Insurance CompanyGEICOPROGRESSIVEALL STATESTATE FARMLIBERTY MUTUALNATIONAL GENERALNATIONALUTICAUTICA NATIONALTRAVELERSUSAACHUBBCOUNTRY WIDETHE GENERALNATIONWIDEESURANCEFARMERSTHE HARTFORDMETLIFESAFECOSENECAEMPIREERIEMAPFRERLISELECTIVEFIREMANS FUNDS INSURANCEFARM INSURANCESENTRYINTERSTATE IDEMNITYINTERBOROKANSAS CITY FIRE AND MARINE INSURANCELIBERTY MUTUAL FIRE21st CENTURYWESCOLM INSURANCENOVAHANOVERAMERICAN TRANSITHARLEYSVILLEHEREFORDINFINITYLANCERCINCINNATIKINGSTONEZURICHFOREMOSTMAIDSTONEAMERIPRISEBERKLEYMIDCENTURYAMICABERKSHIREAmGUARDOTHER Insurance Name: 4Vehicle Make & Year Make of your Car: Select MakeAcuraAudiBentleyBMWBuickCadillacChevroletChryslerDodgeFiatFordFerrariGMCHondaHyundaiInfinitiIsuzuJaguarJeepKiaLand RoverLexusLincolnMaseratiMazdaMercedes BenzMiniMitsubishiNissanPorscheSAABSaturnScionSmartSubaruSuzukiTeslaToyotaVolkswagenVolvoOther Year of your Car: Select Year1984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Model of your Car: Color:Select ColorRedWhitePearl WhiteBlueBlackBrownYellowGreenGreySilverOther Damage Report Problem: "What's wrong with my car?" Add Your Signature For your Insurance Company Authorization to Repair: I hereby authorize BLUE STAR BROTHERS Inc.to perform all needed repairs to my vehicle in accordance with the estimate of repairs, as well to you authorize us to drive your vehicle on roads and highways to diagnose, repair, service and inspect the vehicle. Direction of Payment: I hereby authorize BLUE STAR BROTHERS Inc.to accept on my behalf any and all payments for credit on my account for repairs on my vehicle which have been released and accepted. Please Sign Below [/vc_column][/vc_row][vc_row el_id=”formRow”][vc_column][/vc_column][/vc_row]
