Work Auth / Payment Req 2017-09-23T19:36:23+00:00

GO PRO CONSTRUCTION AND RESTORATION INC.

1930 VETERANS MEMORIAL HIGHWAY, STE 12, ISLANDIA NEW YORK 11749
EMAIL: GOPRO4012@GMAIL.COM
PHONE: (844) 517-8418
FAX: (631) 410-5522

 

WORK AUTHORIZATION AND DIRECT PAYMENT REQUEST

THIS AUTHORIZATION IS MADE

ON THIS DAY OF :



BY AND BETWEEN GO PRO CONSTRUCTION AND RESORATION INC, HEREINAFTER REFERRED TO AS THE COMPANY, AND

Name :



HEREINAFTER REFERRED TO AS THE CUSTOMER, TO PROCEED WITH ITS RECOMMENDED PROCEDURES TO PRESERVE, PROTECT AND SECURE FROM FURTHER DAMAGE THE PROPERTY LOCATED AT

Property Address :



PROVIDING THE CUSTOMER HAS VALID EFFECTIVE INSURANCE COVERAGE FOR ALL OR PART OF THE SERVICES TO BE PERFORMED BY THE COMPANY, THE CUSTOMER FURTHER AUTHORIZES AND DIRECTS THEIR INSURANCE CARRIER TO PAY THE COMPANY DIRECT, AND TO NAME THE COMPANY ON ANY AND ALL INSURANCE DRAFTS APPLICABLE TO THIS LOSS. IN THE EVENT THE CUSTOMER WITHHOLDS ANY FUNDS PAID BY THE INSURANCE/MORTGAGE COMPANY WHICH IS DUE TO THE COMPANY, THE CUSTOMER WILL BE CHARGED A FEE IN THE AMOUNT OF $250.00 PER DAY UNTIL FULL PAYMENT IS PAID. TIME IS OF THE ESSENCE FOR ALL PAYMENTS DUE TO THE COMPANY.

THE COMPANY SHALL BILL ALL CHARGES AND/OR COSTS DIRECT TO THE CUSTOMER AND, AS A COURTESY ONLY; A COPY OF THESE INVOICES SHALL BE MAILED TO THE INSURANCE CARRIER. IT IS FULLY UNDERSTOOD AND AGREED TO BY THE CUSTOMER THAT ANY AND ALL CHARGES ARE DUE UPON COMPLETION OF WORK. IT IS FULLY UNDERSTOOD THAT THE CUSTOMER IS PERSONALLY RESPONSIBLE FOR ANY AND ALL DEDUCTIBLES, DEPRECIATION OR ANY CHARGES OR COSTS NOT COVERED BY THE INSURANCE. ANY AND ALL CHARGES FOR SERVICE NOT REIMBURSED BY AN INSURANCE CARRIER ARE AT THE SOLE RESPONSIBILITY OF THE CUSTOMER AND ARE TO BE PAID UPON COMPLETION OF WORK. ANY EXCEPTION MUST BE APPROVED BY THE COMPANY GENERAL MANAGER, AND A FINANCE CHARGE OF 1.% PER MONTH (MINIMUM OF $5.00) WILL BE APPLIED TO ANY UNPAID BALANCE AFTER THIRTY (30) DAYS.

THE LIABILITY OF TE COMPANY IS EXPRESSLY LIMITED TO THE TOTAL AMOUNT OF THE SERVICES AUTHORIZED HEREIN AND IN NO EVENT SHALL THE COMPANY, ITS AGENTS OR ASSIGNS BE LIABLE FOR CONSEQUENTIAL DAMAGES OF ANY KIND. IN THE EVENT ANY LEGAL PROCEEDINGS MUST BE INSTITUTED TO RECOVER THE AMOUNT DUE, THE COMPANY SHALL BE ENTITLED TO RECOVER THE COSTS OF COLLECTION INCLUDING REASONABLE ATTORNEYS FEES.

EXECUTED AT :



ON THE DAY AND YEAR FIRST ABOVE WRITTEN.

PRINT NAME :
TITLE :
POLICY/CLAIM NUMBER :


AUTHORIZED SIGNATURE OF
INSURED OR ACTING AGENT :



YOUR DIGITAL SIGNATURE IN THE ABOVE FIELD CONSTITUTES ENTERING INTO A LEGALLY BINDING AGREEMENT.