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
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 ,
(Insured or Acting Agent)
Our File #:_______________________________