TLE Emergency Work Authorization Form

EMERGENCY WORK AUTHORIZATION AND ASSIGNMENT OF INSURANCE BENEFITS *

I authorize TRIANGLE LEGACY FLOOD RESTORATION & CARPET CLEANING
("Contractor"), to do all work it deems necessary for
Name *
mitigation and/or emergency repairs to my property at the address below. This work authorization, along with all approved scopes of work, shall constitute the contractual obligations of the
Owner and Contractor. *

I understand that the Contractor has no connection with my insurance company or its adjuster, and that I have the authority to authorize contractor to make any repairs. I agree that any portion of work, such as deductibles, betterment depreciation or additional work requested by me not covered by insurance must be paid by me. I agree to pay the deductible in the amount of $
$ Amount *
to the contractor prior to the commencement of the work.
*

I also authorize TRIANGLE LEGACY FLOOD RESTORATION & CARPET CLEANING to supply information regarding the claim to my Insurance Company;
Insurance company *
and to make a full report of all work done by TRIANGLE LEGACY FLOOD RESTORATION & CARPET CLEANING and I authorize my insurance company to review and approve Contractor's estimate promptly after receipt of same.
ASSIGNMENT *

I hereby irrevocably and absolutely assign to TRIANGLE LEGACY FLOOD RESTORATION & CARPET CLEANING all payments and proceeds for the work performed hereunder to contractor, and I authorize my insurance company to pay all proceeds due contractor payable under my policy directly to contractor. Payments shall be either mailed directly to contractor's office or hand-delivered to contractor's representative only. If my name is included on any said payment, I understand that this form constitutes a contrct for services performed and acknowledge that temporary repairs do not carry any guarantee.
DISCLAIMER *

Customer acknowledges that when TRIANGLE LEGACY FLOOD RESTORATION CARPET CLEANING attempts to restore items which were damaged by fire, wind, water, vandalism or other traumatic occurrence, permanently discolored, faded and/or bleached areas might remain even though TRIANGLE LEGACY FLOOD RESTORATION & CARPET CLEANING covenants to use every diligent effort and means available to remove all spots.
*

Customer understands that there is no guarantee that in all circumstances items can be restored to their condition prior to the disaster. In the case of items made of, or covered with fabric, there may be shrinkage, fugitive colors, fabric separation, changes in texture and other hidden conditions such as loose carpet or tackless strip, improperly laid carpet, broken seams, delamination or permanent deterioration that cannot reasonably be anticipated prior to restoration or cleaning attempts.
*

In the event that these items cannot be restored to pre-disaster conditions, normal recourse is to file an additional damage claim under the appropriate insurance policy provisions. TRIANGLE LEGACY FLOOD RESTORATION & CARPET CLEANING SERVICES will not be held responsible for such conditions. Any corrections made because of the above-named conditions are the owner's responsibility together with any cost involved in correcting these conditions.
Waiver of Right to Cancel
I acknowledge that the goods and services provided hereunder are emergency services and authorize Contractor to proceed with the work without delay. By requesting that the contractor undertake its work immediately, I understand that I am waiving my rights to cancel this transaction under the provisions of the Virginia Home Solicitation Sales Act and/or similar consumer protection laws. *

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INSURED (PRINT NAME):
Insured (Print Name) *
DATE OF LOSS *

Month Day Year
Date
SERVICE ADDRESS:
Service Address *
AUTHORIZATION SIGNATURE *

Clear
Date Signed *
DATE SIGNED

TRIANGLE LEGACY'S REPRESENTATIVE: DATE SIGNED:
TRIANGLE LEGACY'S REPRESENTATIVE:
Triangle Legacy's Representative
Date Signed
Should be Empty:

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Waiver of Right to Cancel

INSURED (PRINT NAME):

SERVICE ADDRESS:

TRIANGLE LEGACY'S REPRESENTATIVE: