CONTRACT AND AUTHORIZATION OF THE INSURED

BRONCO CATASTROPHE SERVICES, INC. I CARDINAL CATASTROPHE SERVICES, INC. I CAROLINA CATASTROPHE SERVICES, INC. | LONE STAR CATASTROPHE SERVICES, INC. | NASHVILLE CATASTROPHE SERVICES, INC. | VIKING CATASTROPHE SERVICES, INC.
INSURANCE RESTORATION CONTRACT AND AUTHORIZATION OF THE INSURED
INSURED NAME

First NameLast Name
ADDRESS
Insurance CARRIER
POLICY NUMBER
CLAIM NUMBER
ACCEPTANCE OF AGREEMENT
By signing below, I, the Insured, understand that this document serves as authorization of UCS to communicate with and negotiate with my Insurance Carrier to obtain a contract for construction work as approved by my Insurance Carrier. The terms, specifications, and conditions listed above and on the reverse side of this page and all matters incorporated herein by reference, including signed proposal and specification pages if applicable, constitutes the entire agreement between the parties. This agreement is hereby deemed satisfactory and accepted. UCS is authorized to perform the work as specified.
AUTHORIZED SIGNATURE

Clear
DATE

MonthDayYear
Date
PRIMARY PHONE
ADDITIONAL PHONE
Email
example@example.com
Should be Empty:

INSURANCE RESTORATION CONTRACT AND AUTHORIZATION OF THE INSURED