Indiana Emergency Restoration Company

Mitigation Work Authorization Form

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

We hereby retain and hire Five Star Complete Restoration, Inc. to perform emergency water damage services, sewage mitigation, and/or any associated services, including repair with respect to property which we own, control or lease and for which we have the right and power to contract such services. If property address differs, please fill out the following:
The undersigned hereby assigns and subrogates to Five Star Complete Restoration, Inc., all right, title, and interest the undersigned may have to any and all proceeds from any and all policies of insurance that may provide coverage for the loss incurred and for the services rendered under this Work Authorization. This assignment and subrogation specifically includes the right to make application for coverage, to file proof of loss, and to receive payment directly from any insurance company, without further authorization or consent of the undersigned. The undersigned specifically authorizes and requests the insurance company to make and deliver all payments for loss solely and directly to Five Star Complete Restoration, Inc.
We also agree to make prompt payment of any deposit, deductibles or monies owed for the services rendered which are not covered by and/or paid by our insurance company.
Furthermore, we agree to pay Five Star Complete Restoration, Inc., upon receipt of their final invoice, for the services rendered in accordance with this work authorization. In the event this account is in default, we agree to pay attorney’s fees and other collection cost incurred, whether suit is filed or not. We agree to pay 2.0% per month on any unpaid balance after default, and on such fees and costs incurred until fully collected, paid or lawfully discharged. Default shall be considered to have occurred thirty (30) days after receipt of invoice for services rendered herein.
Customer is responsible for securing or removing sensitive items from the property, including the following, but not limited to: fire arms, prescription medicated, recreational drugs, sensitive documents, etc.

Translate »

Home / Forms / Mitigation Work Authorization Form