Authorization To Pay - Mark Scott Construction Inc

STATEfARMte\~INSURANCEeInsured_ClaimNumb er_AuthorizationToPay(To Be SignedUponCompletionof Services/Repairs)TO: StateFarm GeneralInsuranceCompanyI understandthis AUTHORIZATIONTO PAY extendssolelyfor the servicesor repairexpensescoveredby my StateFarm GeneralInsuranceCompanyinsurancepolicyas a resultof the loss occurringon. I agreeto pay my indepen-dent contractorand/orindependentserviceprovid er(s)for any servicesor repairsor additionalimprovementsmadeat my directionthat are not coveredundermy have receiveda copy of my independentcontractor/serviceprovider(s) final estimate(s),andwrittenworkmanshiplabor warrantyon the buildingor of the buildingor structuralservices/repairsby thiscontractor/serviceproviderhave been completedto my authorizepaymenton my behalfin the abovereferencedclaim to_for the amountshownon the final estimate(s)or the invoicessent to StateFarm GeneralInsuranceCompanyfrom my independentco

STATE fARM te\ ~ INSURANCE e Insured _ Claim Number _ Authorization To Pay (ToBeSigned Upon Completion ofServices/Repairs) TO: State Farm General Insurance Company

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