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

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

I/We have reviewed all of the repairs performed and completed by Five Star Complete Restoration Inc. I/We certify that all work performed and materials supplied in accordance with the signed work authorization have been completed and/or supplied to my/our satisfaction. 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.

Signature of Insured:

Insurer's signature*

Date*

Insurer's signature

Date

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