Please fill out and submit the form below, or download the form here to print and complete.

Name*

First Last

Date*

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

The undersigned has reviewed all of the content packout services performed by Five Star Complete Restoration, Inc. The undersigned certifies that all work performed in accordance with this signed work authorization have been completed to the undersigned’s satisfaction.

The undersigned specifically authorizes all funds or proceeds from any policies or resulting coverage from any insurance company or contributing party other than an insurance provider (i.e. self-pay scenario) to make and deliver all payments for loss solely and directly to Five Star Complete Restoration Inc.

The completion date for this loss is*

Customer's signature

Date*

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