HORACE MANN INSURANCE

DIRECTION OF PAYMENT

Claim # ________________________________

Insured Name: ________________________

Claimant Name: _______________________

I authorize Horace Mann Insurance Company to make payment, on my behalf, directly to

Repairer Name ____C.A.R. Collision Center_______

Repairer Address ____7967 Twist Lane____________

City, State, Zip ____Springfield, VA 22153__________

Tax ID Number ___412235434__________________

For and authorized repairs, and for which I am entitled to be compensated, resulting from the above captioned claim.

Printed Name _________________________________

Signature ____________________________________

Date _______________________