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

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Date*

The undersigned has reviewed all of the demolition and dry out performed by Five Star Complete Restoration, Inc. The undersigned certifies that all work performed in preparation for repairs 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.

Completion date for this loss*

Customer's signature*

Date*

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