Certificate of Completion

Certificate of Completion
Policyholder Name*

First NameLast Name
Policyholder Email*
example@example.com
2nd Policyholder Name (if applicable)

First NameLast Name
Policyholder Worksite Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policyholder Claim Number*
Current Adjuster's Email Address (this will automatically email them the COC, saving time!!!)*
example@example.com
Current Restoration/General Contractor Company Name*
Current Restoration/General Contractor Project Manager Email Address (this will automatically alert them you signed COC)*
example@example.com
The Client acknowledges by signing below, that the project work for the property claim provided has been completed to the customer’s (or if applicable, lien holder’s) satisfaction and that the name, address, and claim number filled in above are correct and correlate to the Signature and Date below.
Signature*
Date*

MonthDayYear
Date
Should be Empty: