Third Party Work Authorization

This authorization is made this _______ day of ____________, 19____ by and between YOUR COMPANY NAME (Y.C.N.) hereinafter referred to as (Y.C.N.), and PROPERTY OWNER/CLAIMANT presently residing at PROPERTY OWNER/CLAIMANT’S BILLING ADDRESS herein after referred to as CUSTOMER.

The CUSTOMER authorizes Y.C.N. to proceed with its recommended procedures to preserve, protect and secure from further damage the property located at LOSS ADDRESS OR SAME AS ABOVE, IF APPLICABLE and with the understanding that NAME OF LIABLE THIRD PARTY is hereby responsible for all services and charges to be performed by Y.C.N., as authorized by NAME OF PERSON REPRESENTING THIRD PARTY, and the CUSTOMER further authorizes and directs NAME OF LIABLE/ THIRD PARTY to pay Y.C.N. direct.

It is fully understood that the CUSTOMER is personally responsible for and all charges, deductible, and depreciation not covered by NAME OF LIABLE THIRD PARTY. Any exceptions must be approved by Y.C.N. General Manager. The liability of Y.C.N. is expressly limited to the total amount of the services authorized herein and in no event shall Y.C.N. its agents or assigns, be liable for consequential damages of any kind. Y.C.N. shall not be responsible for and mysterious disappearances of any personal property or contents. In the event any legal proceedings must be instituted Y.C.N. shall be entitled to recover the cost of collection including reasonable attorney’s fees. All charges and costs are due upon completion of work. Late charges of 1.5% per month (minimum of $1.00) will be charged on any unpaid balance after thirty (30) days.

Executed at NAME OF COUNTY, STATE on the day and year first above written.

Authorized Signature:

(Claimant or Acting Agent)

Print Name:
Title: PROPERTY OWNER/CLAIMANT
Policy/Claim #:
Purchase Order #: IF APPLICABLE
Our File #: YOUR JOB NUMBER

YOUR COMPANY NAME
 REPRESENTATIVE OF YOUR FIRM
Title:
Signature of: NAME OF PERSON FROM THIRD PARTY
Representative: THEIR SIGNATURE IF AVAILABLE

 

 

Notes About the

Third Party Work Authorization
  1. Be sure to retain the original.
  2. Issue a copy to signing party (claimant) and third party representative (if applicable).
  3. Send a copy to liable/third party with your invoice if they did not receive one at the job site.
  4. Highlight "Direction of Payment Clause" below.
  5. Note on your invoice:

WE REQUEST DIRECT PAYMENT AS ASSIGNED BY THE CLAIMANT