Direction to Pay (DTP)

THIS IS A CONTRACT BETWEEN THE INSURED AND DALLAS FAMILY DENT, LLC

Service Representative

Service Coordinator

Customer Information

Full Name

Address

City

State

ZIP

Is this the address where the damage occurred?

Phone

Referred By

Vehicle Information

Year

Make

Model

Color

License Plate

Plate State

VIN

Insurance Information

Insurance Provider

Policy Number

Policy Start

Policy Exp.

Claim Number

Deductible

Rental / Day

Adjuster Name

Adjuster Email

Adjuster Phone

Ext

Notes

Dallas Family Dent — Direction to Pay / ATRPage 1 of 2

Authorization to Repair (ATR)

THIS IS A CONTRACT BETWEEN THE INSURED AND DALLAS FAMILY DENT, LLC

Please read and initial each of the numbered provisions below, then sign and date.

Text Message Consent (SMS). By signing below, I agree to receive text messages from Dallas Family Dent at the mobile number I provided regarding my appointment, repair status, insurance claim, payments, and account verification codes. Message frequency varies. Message and data rates may apply. Reply HELP for help or STOP to cancel. Consent is not a condition of any purchase or service.

Sign here

Customer Signature

Date

Dallas Family Dent — Direction to Pay / ATRPage 2 of 2