Harshbarger Enterprises NTI GA

Policyholder's Information
Full Name(s)
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Loss Address (Type Street Address, City, Zip Code)
Primary Address (if different from loss address)
Date of Loss I Date of Discovery

MonthDayYear
Date
Description of Loss (Wind/Hail, Fire, Water, etc...)
Insurance Information
Insurance Carrier(s) Name
Policy Number
Claim Number/Roofing Company
Insured:

By signing this agreement, the insured hereby authorizes Harshbarger Enterprises LLC to initiate and maintain communication with the insurer and its representatives on behalf of the insured as the insured's representative
First Named Insured's Printed Name
First Named Insured's Signature
Date

MonthDayYear
Date
Second Named Insured's Printed Name (if applicable)
Second Named Insured's Signature (if applicable)
Date

MonthDayYear
Date
Limited Power of Attorney

I (the "Principal") hereby make, constitute, and appoint Harshbarger Enterprises LLC. to be my true and lawful "Attorney in Fact"
Principal's Full Name
Principal's Name (Print):
Principal Signature:
Date:

MonthDayYear
Date
Should be Empty:

Insurance Information