Rockwell Indoor Environmental - Syracuse, NY

Work Authorization & Direction to Proceed
with Direct Billing to Insurance Carrier
Ins. Carrier
Contact
Policy #
Claim #
I hereby authorize ROCKWELL to proceed with
in conjunction with the loss related to
which occurred on or about
Further, I authorize ROCKWELL to invoice all work performed directly to, and receive payment directly from, the Insurance Carrier listed above in reference to the claim # provided to ROCKWELL, by me, the property owner and/or authorized representative.
As the Property Owner / Authorized Representative I understand that invoices for all work performed will be submitted to the Insurance Carrier for payment. Should I receive payment directly from the Insurance Carrier or should all or any part of this claim be denied for any reason, I/we acknowledge that the Property Owner remains solely responsible for prompt payment for all services rendered. In the event it becomes necessary to pursue collection from the Property Owner, ROCKWELL shall be entitled to all reasonable costs of collection or enforcement, including without limitation, counsel fees, court costs and other expenses incurred in connection with the collection effort.
This Agreement shall be construed and governed in accordance with the laws of the State or New York. The agreed upon venue is the County of Onondaga, State of New York.
Initials Of Authorized Representative
Insured/Authorized Signature
Date
MM slash DD slash YYYY

Work Authorization