Work Authorization 

 and Direct Payment Request

This authorization is made this_____ day of_____________, 20___ by and between 

The Steam Team hereinafter referred to as The Company, and 

_____________________________________ hereinafter referred to as the CUSTOMER, 

to proceed with its recommended procedures to help preserve, protect and secure from 

further damage the property located at________________________________________ 


Providing the CUSTOMER has valid effective insurance coverage for all or part of 

the services to be performed by The Company, the CUSTOMER further authorizes and

directs their insurance carrier to pay The Company direct, and to name The Company on

any and all insurance drafts applicable to this loss. 

The Company shall bill all charges and/or costs direct to the CUSTOMER and, as a 

courtesy only, a copy of these invoices shall be mailed to the insurance carrier. It is fully 

understood and agreed to by the CUSTOMER that any and all charges are due upon 

completion of work. It is fully understood that the CUSTOMER is personally responsible 

for any and all deductible, depreciation or any charges or costs not covered by insurance. 

Any and all charges for services not reimbursed by an insurance carrier are the sole 

responsibility of the CUSTOMER and are to be paid upon completion of work. Any 

exceptions must be approved by The Company General Manager, and a finance charge 

of 1.5% per month (minimum of $2.00), will be applied to any unpaid balance after thirty 

(30) days. 

The liability of The Company is expressly limited to the total amount of the services 

authorized herein and in no event shall The Company, its agents or assigns, be liable for 

consequential damages of any kind. In the event any legal proceedings must be instituted 

to recover the amount due, The Company shall be entitled to recover the cost of

collection including reasonable attorney's fees. 

EXECUTED AT_______________,__________ on the day and year first above written. 

County State , 

Authorized Signature:______________________________ 

 (Insured or Acting Agent) 

 Print Name:_______________________________ 


 Policy/Claim #:_____________________________ 

Our File #:_______________________________