Transcription of Authorization To Pay - Mark Scott Construction Inc
1 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)
2 Or the invoicessent to StateFarm GeneralInsuranceCompanyfrom my independentcontractoror independentserviceprovider(s)and the materialsupplier(s).I understandthat my propertylenderand/orits authorizedrepresentative,if thereis a propertylien, may performits own inspectionof my damagedpropertyto verifythat the buildingor structuralservices/repairsas disclosedon the final estimate(s)have been :Anypersonwhoknowinglypresentsa falseorfraudulentclaimforthepaymentofa lossisguiltyofa crimeandmaybesubjecttofinesandconfinemen tinstateprison.
3 (Date)(Year)(InsuredSignature)
