WATER RESTORATION CALL/JOB REPORT

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Laurence Singleton
6 years ago
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WATER RESTORATION CALL/JOB REPORT Job Information Date: Time Called In: Date of Loss: Job #: Contact Person (POC): Relationship: Job Address: City: State: Zip Code: Work Phone: Cell Phone: Email:

1 WATER RESTORATION CALL/JOB REPORT Job Information Date: Time Called In: Date of Loss: Job #: Contact Person (POC): Relationship: Job Address: City: State: Zip Code: Work Phone: Cell Phone: Directions to Job: Insured Information Name of Insured: Bill Address: City: State: Zip Code: Fax: Work Phone: Hotel: Hotel Phone: Other: Insurance Information Insurance Company: Policy # Insurance Agency: Contact Person: Address: City: State: Zip Code: Phone: Fax: Adjusting Company: City: State: Zip Code: Adjuster: Phone: Zip Code: Fax: Deductible: Claim #

2 What is the source of the water and the location of the problem? Telephone Questions Windows/doors need boarding up? Has the water source stopped? Is your furniture in water? Do you have electricity available? Have you called the Insurance Company? Areas Affected: Types of Flooring Affected: Date & Time Called In: Time On Site: Yes No Yes No Yes No Yes No Yes No Upstairs Dining Room Downstairs Kitchen Hall Bedroom Den Bathroom Living Room Study Hardwood Carpet Tile Laminate Linoleum Other Time Call Returned: Date & Time Estimate Completed:

3 EMERGENCY SERVICE AGREEMENT 1) Parties. This agreement is entered on this day of (month), (year) by and between Triangle Legacy Flood Restoration & Carpet Cleaning, and (Customer). The real and/or personal property located at (Property Address), has been and currently is damaged due to the following conditions:. In order to lessen the damage, Customer has retained Triangle Legacy Flood Restoration & Carpet Cleaning to enter the PROPERTY and furnish materials, equipment and labor to reasonably protect and secure the PROPERTY from further damage and/or to commence restoration procedures reasonably necessary to restore the property and contents to as near their pre-loss condition as reasonably possible. 2) Payment. Customer acknowledges that the current conditions present at the PROPERTY make it impossible for Triangle Legacy Flood Restoration & Carpet Cleaning to render an accurate quotation of the cost and scope of repairs before commencing work. The Property is insured by the following company or companies Policy Number(s) Customer/Agent Initials): ATTENTION INSURANCE COMPANY: I hereby assign all sums due or to become due in connection with this work to Triangle Legacy Flood Restoration & Carpet Cleaning and instruct you to make payment directly to Triangle Legacy Flood Restoration & Carpet Cleaning, and name Triangle Legacy Flood Restoration & Carpet Cleaning on all drafts and checks made in payment for this loss. 3) Billing. At the discretion of Triangle Legacy Flood Restoration & Carpet Cleaning, invoices may be sent directly to the Insurance Provider. Should payment in full or in part be denied by the Insurance Provider, the Customer will pay such costs directly to Triangle Legacy Flood Restoration & Carpet Cleaning. Customer has been informed about and agrees: a) Customer is personally responsible for any and all deductible(s), depreciation, services and/or charges not paid by insurance; and b) Invoices not paid by insurance are payable upon receipt. Interest at the highest rate allowed under Provincial law will be charged on any unpaid balance after thirty (30) days of the date of invoice. Customer agrees to pay all

4 collection costs, collection agency commissions, attorneys fees, expert fees, court costs and arbitration costs incurred by Triangle Legacy Flood Restoration & Carpet Cleaning to collect past due balances. This attorneys fees provision is expressly limited to actions on the contract and shall not be interpreted or construed to apply to any other claims. Customer/Agent Initials: 4) Limit of Liability. Triangle Legacy Flood Restoration & Carpet Cleaning s liability is limited to the total amount paid to Triangle Legacy Flood Restoration & Carpet Cleaning for services rendered. Customer hereby agrees to release, hold harmless, defend (pay attorneys fees, expert fees, arbitration costs and court costs) and indemnify Triangle Legacy Flood Restoration & Carpet Cleaning from any and all damages, claims or actions that arise from: a) Conditions that pre-existed the specific loss or event Triangle Legacy Flood Restoration & Carpet Cleaning was hired to address; b) the premature removal of equipment or termination of work against Triangle Legacy Flood Restoration & Carpet Cleaning s recommendations; c) any refusal to allow Triangle Legacy Flood Restoration & Carpet Cleaning to perform any procedures it recommends; and d) Mysterious disappearances of personal property. Problems that may occur for which Triangle Legacy Flood Restoration & Carpet Cleaning will be released, indemnified, defended, and held harmless may include mold, bacteria, structural damage, indoor air quality contamination, and environmental illnesses (including allergies, asthma and alleged toxic effects). Customer/Agent Initials: DESCRIPTION OF PRE-EXISTING DAMAGE: I have read, understand and agree to the above. I am the owner of the property/structure or am authorized to enter this agreement on behalf of the owner of the structure. I understand that the Customer is personally responsible for any and all charges, costs and deductibles not covered by insurance. CUSTOMER(S) (must be at least 18 years old) Signature circle one: Owner/Agent Print Name and Title: Triangle Legacy Flood Restoration & Carpet Cleaning Signature: Print Name and Title:

5 OCCUPANT AUTHORIZATION OCCUPANT: CUSTOMER: Job Site Address: 1) Services. Triangle Legacy Flood Restoration & Carpet Cleaning ( Triangle Legacy ) has been retained by the Customer identified above to provide the services generally described as: 2) Unrelated Conditions. Occupant acknowledges and agrees that Triangle Legacy is not responsible for addressing or correcting damages, conditions, or areas unrelated to the event that necessitated the services described in paragraph 1, above. 3) Special/Fragile/ Valuable Items. Occupant agrees to take full responsibility for special, fragile, or valuable items or personal property, and that Triangle Legacy shall not be liable for mysterious disappearances or damage to any such items. Triangle Legacy Restoration & Carpet Cleaning highly recommends that the Occupant take care to protect any such items as soon as possible, preferably prior to the start of work (especially jewellery, cash, weapons, medications, etc.). Occupant agrees that Triangle Legacy shall not be liable for: a) conditions that preexisted the specific event that Triangle Legacy was hired to address; b) Harm that results from the premature removal of equipment or termination of work against Triangle Legacy s recommendations; and c) Harm that results from any refusal to allow Triangle Legacy to perform the procedures it recommends. Occupant/ Agent Initials: 4) Environmental Conditions. Occupant understands and the parties agree that certain amounts of mould and bacteria may be normal in an indoor environment, and Triangle Legacy is not attempting to leave the work area sterile. Occupant understands that the presence of certain types of microorganisms in indoor environments can cause illness and/or damage to the property, and that the use of certain chemicals may reduce this risk. Occupant hereby acknowledges that Triangle Legacy has advised Occupant of the importance of ventilation. Infants, the elderly, and individuals with chemical sensitivities or respiratory problems may be particularly sensitive to certain types of microorganisms. 5) Information Needed. Occupant shall provide Triangle Legacy with complete available information regarding known relevant or potentially relevant facts about the history of the structure and the conditions in and around the Job Site. Occupant is responsible for advising Triangle Legacy of the known existence of hazardous substances (including chemicals, lead, asbestos, etc) or areas of possible danger. 6) Access and Security. Occupant agrees to provide free and unrestricted access to the Job Site Address to Triangle Legacy s Employees, Agents and Subcontractors, and their vehicles and equipment. Occupant will

6 provide areas for storage of equipment, materials and debris. Triangle Legacy may store equipment and materials in the areas provided by the Occupant at the end of each workday. Occupant will provide all water, electricity, and other utilities necessary for Triangle Legacy to perform work. Occupant will secure all entrances to the Job Site Address in a manner adequate to prevent unauthorized persons from gaining access. Occupant understands that he/she is responsible for the care and custody of any equipment and materials while Triangle Legacy is not on site. Occupant will pay the reasonable repair and/or replacement cost of any lost, stolen, or damaged equipment or materials. 7) I have received a copy of Triangle Legacy s Notice, Disclosure, and Disclaimer. Occupant/Agent Initials: I authorize TRIANGLE LEGACY to perform the services described above, and I agree to the terms above CUSTOMER(S) (must be at least 18 years old) Signature circle one: Owner/Agent Print Name and Title: Triangle Legacy Flood Restoration & Carpet Cleaning Signature: Print Name and Title:

7 BIOCIDE AUTHORIZATION AND RELEASE Job Site Address: Date: 1) Environmental Conditions. Triangle Legacy has recommended the use of certain biocides, antimicrobial products or other chemical agents to kill or inhibit the growth of microorganisms such as mould and bacteria. Owner understands that the use of certain chemicals may reduce the risks associated with biological contamination. 2) Notification of Risks. Triangle Legacy has advised Owner of the importance of ventilation, and that the use of chemicals in an indoor environment may pose potential health risks to susceptible individuals, including respiratory and irritant effects. Owner hereby acknowledges that Triangle Legacy will provide Owner upon request, with a copy of the Material Safety Data Sheets (MSDS). Owner acknowledges and understands that MSDS sheets are prepared by the manufacturers of the chemicals---and not Triangle Legacy. 3) Opportunity to Seek Medical Opinion. Owner hereby acknowledges that he/she has had an opportunity to seek a medical opinion on the potential health effects of antimicrobial products and biocides. 4) RELEASE. OWNER ACCEPTS AND ASSUMES ALL RISKS AND DANGERS THAT MAY RESULT FROM THE USE OF CHEMICAL PRODUCTS, INCLUDING THE RISKS DESCRIBED ABOVE. OWNER HEREBY AGREES TO RELEASE, DEFEND, AND HOLD HARMLESS TRIANGLE LEGACY, ITS SUCCESSORS, PREDECESSORS, AGENTS, PRINCIPALS, FRANCHISORS, SUBCONTRACTORS, AND EMPLOYEES FROM CLAIMS OF DAMAGE, AND HEALTH EFFECTS RESULTING FROM THE APPLICATION OF ANY CHEMICAL PRODUCT. Election

8 I ACCEPT: I hereby authorize the use of antimicrobial products and I agree to the release above. Owner/Agent Initials: I DECLINE: I refuse to allow the use of antimicrobial products and I assume the risk that may result, as described in paragraphs 1 and 2, above. Owner/Agent Initials: I AM THE OWNER OF THE PROPERTY/STRUCTURE OR AM AUTHORIZED TO ENTER THIS AGREEMENT ON BEHALF OF THE OWNER OF THE STRUCTURE. Owner/Owner s Agent Signature circle one: Owner/Agent Print Name and Title: Triangle Legacy Flood Restoration & Carpet Cleaning Signature: Print Name and Title:

9 Customer Instruction/ Responsibility Form (Regarding the equipment left at your property) General: Our equipment will increase the rate of drying and reduce the amount of time you are displaced! Do not turn off or move equipment without first calling Triangle Legacy Flood Restoration & Carpet Cleaning. Do not open the windows unless instructed by our Service Professional, as this may retard the drying process. Limit entering affected rooms. Do not allow children to play near equipment. Keep temperature between F (21-30 C) for drying conditions. Safety and Health: If dehumidifiers or air movers must be moved; they must first be turned off and unplugged as it may be hazardous to move these units while they are operating. Exposed tackless strip is a danger even when covered; take care when walking near tackless strip. Floors may be slippery when wet; take extreme care when walking on or from wet flooring materials. Equipment Responsibility: The Customer is responsible for loss or theft of the following numbered drying equipment.

10 EQUIPMENT LOG Detailed log of equipment left at your property Equipment On-Site Type Room Comment Air Mover Control #s Date Installed Date Removed Dehumidifier Control #s Other Equipment on site I have read and understand the information above about equipment operation, equipment responsibility and safety precautions Service Professional: Date: Customer Signature: Date:

11 CONTRACT CHANGE ORDER PROJECT Name: Address: TO CONTRACTOR Name: Address: City: State: Zip Code: City: State: Zip Code: Phone: Fax: Phone: Fax: The contract is hereby modified and amended as follows: It is mutually agreed that the contract price is (increased/decreased) by $ payable prior to commencing work noted above. As a result of this change order, the time for completion of the above-mentioned contract is hereby extended by an additional days. This change is governed by the above-mentioned contract and is incorporated therein. Contractor: Owner/Agent or Owner: Date: Date:

12 CERTIFICATE OF COMPLETION AND SATISFACTION Insured/Claimant: Loss Address: Insurance Company (if applicable): Policy # Claim # Our File # This will certify that the repairs made by Triangle Legacy Flood Restoration & Carpet Cleaning at the above-mentioned property has been completed to our entire satisfaction. These services were necessitated by a (type of damage). Damage loss suffered on (Month/Day/Year). Triangle Legacy Flood Restoration & Carpet Cleaning Authorized Signature: Print Name: Title: Our File # Customer Authorized Signature (Customer or Acting Agent): Print Name: Title: Policy/Claim # Comments: 12

INDEPENDENT CONTRACTOR/VENDOR AGREEMENT

INDEPENDENT CONTRACTOR/VENDOR AGREEMENT This Agreement, made on ( Effective Date ) by and between Owner Representative: HomeRiver Group (Hereinafter Owner s Representative ) and Contractor: (Hereinafter