Policyholder's Information
Full Name(s)
*
Phone Number
*
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
*
-
Month
-
Day
Year
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
*
-
Month
-
Day
Year
Date
Second Named Insured's Printed Name (if applicable)
Second Named Insured's Signature (if applicable)
Date
-
Month
-
Day
Year
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:
*
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: