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<br /> __ . ,.---- --- _. _._.._._ _ _ - - - -- �,_---�- ---- � ------- ---- �
<br /> � ' ' � __.. Authorizatlon to Perform'Services and Dfrection af Payment I
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<br /> � � � ,�� �,/.- ,
<br /> CustomcrNamc: .C�11(�1���%-� �(��1 ,i� '�!:�� \�;-��'� t� Da[co(Loss: ��r_�- Z �
<br /> i.l
<br /> ''i l�'t5 i vr'�•'�110<'i. �'"il/<.
<br /> ��55 nda��55: _L_ � �_�' —
<br /> .+� i-.`. ..i\�� �� � ) r '� !jr.'c.r_' � -
<br /> Cily: . . � ��..�it (. ,. ^� Stite: ,i. 1� Zi�: � �y : .
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<br /> Clienh � ,j� �'(_r,�f:•._�\:VI.�t.�f��!ul<' _. ClaimNmnber(i/avnilo6lc): t,;i�si�:,i�.����fll
<br /> Ihc imdcrsigned dienl, being the huildinG ov,�ner, owner's represcntative, or resldent, autho�izes the Providcr
<br /> icenti(ied belo�.v to perfonn any and all necessary deaninp and/or restoration services on ClienCs property located at
<br /> the property address abuve, and with respect to items that need tn be cleaned at a remote br.ation to iemuve and
<br /> clean.such items as necessary, �
<br /> Client aulhoriirs �`CI'���'�,1��''_lt�.:7!i�_/�i^�_(_Insurance Company,herein re(erredto as"Insurance Company;,
<br /> �---.._--..
<br /> ta pay Provider solely and direclly for lhat pnrtion af the worl<covered by f.licnCs insurance policy.
<br /> If, for any reason, Client iewives a chedc fium Insivance Company made payable to Client, Client agrocs to pay
<br /> Vrovider immediately upon receipt of the chede. In order to ezpedi[e payment to Provider, Client hereby appoints
<br /> Provider as attoiney-In-fact, authorizing Piovider to endorse ClienYs name on Insur3nce Company checks or draRs,
<br /> andtodepozitlnsuianceCtlmpanyched,ordraflsforProviderservices. �
<br /> , Uicnt agree, lo pay Clicnl's deductible in thc amount of $ .._l,��i��__^_ ._ Ihal applics lo this r.laim. li any
<br /> � amounts owing to Provider for Provider:ervices am no[covered by insurence, Client agrees to pay those amounts to
<br /> Provider wilhin flfteen (15�_days of ClienYS receipl of invoice. It. is (ully understood that Client and Its a�ents,
<br /> cucceswrs, a55igns and heirs .-�re personally responsible for any and all dedur.tibles and any wsts not covered hy
<br /> insurance. Interest and finance charges �ti�lll be clwrged at the maximiim allowable hy law, or at 1.59b per month, �
<br /> tohichever is Iess,on accounts over thirty(3U�days past due.Time irof the essence. - � i �,
<br /> Clicnt agrees that�P�ovidcr is wnrking foi Uie Cli�:nt and not CliciiCs insurance r.uinpany or any agent/adjuster. '
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<br /> Property Owned 6y: � �._��-------'-- —T,.y _ i
<br /> �
<br /> Rema�ls: � ���_ `� _/_l�__�dv_��Cf'C=�eZI.�l.�`��/S / s `
<br /> � �- � . � - ----
<br /> �f flc_._L�x�_.��!���i_�L��_l:�►���.._��,�'/�'.,��� .
<br /> ��y/��.-l�ni- ��'1��Qs_ ���._.�v.s�r�_�%�E� _�__u��r�.
<br /> I I�IIIVE RE/1D THIS AUTH 1 ATION TO�DRFORM SERVICES ANU DIRECTION OF PAYMENT,INCLUDING TI1E TERMS
<br /> ANDCONDITIONSO�SERVICEONTHEREVERSrSIDEHEHF.OFANDAGREE7 SAME � ,
<br /> _...�. .. __....._ _� J_ . _ �_.��.�"__'.��. ��t"���_�/'o-l- I
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<br /> YCli�nts.�i�;natutc ` %,r!! j�� �l(�� l�yi}",�1��/� Piovid�r'sSi�nalure _lr��i ._`'l �'_--
<br /> )( Pnnted Namc� ,_ '/jL:,1,1�,r_v����,,i.��� l�� FrSnchise LegalName _,�I �/(,�._ (t �.� �� _ ;
<br /> i — � _
<br /> Clicnl Iie��iewed Custontecl�JormPlion fotnl: �O YO'N . d/b/a SERVPRO"of: .__�.1L�i�+1•L.�� � �< <�,(`ii����}i��,<, �
<br /> � Date (1 '��I ,^�j1 � . �. � natc: � ��:i_�_/I.. .`i�.-- ' �
<br /> ): � �u:-._1�---- ---- �
<br /> ,While: S[RVPHO• Ycllow: Claims Prolessional � Pink: Cuslomer �
<br /> �SERVPRO'INIF.LI.ECiU�LPPOPER1Y,lnc. fdLftIGHT5RE5[RVED FE�0517071.0 1B000 OG/11
<br /> Enah SFJi{Y'N0�frcndJ.rc h LiJ��mJrmlrOmrrvl.n:d O�,r�vrn7. "
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