Georgia

Customer Name *

First

Last

Address

Address Line 1

Address Line 2

City

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Zip Code

Today Date

Email *

Phone

Claim Infomation

Insurance Company

Adjuster Name

Adjuster Email

Description of Loss

• Soft Tissue Clog
• Supply line rapture
• Slab Leak
• Flood

Claim Number

Adjuster Phone

Misc info

Services *

• Demolition
• Drying
• Cleaning
• Mold Testing

Agreement

Services *

• Services: Customer has contracted with Emergency Water Removal (EWR) to perform services needed for mitigation of water and water related damages. Customer is responsible for all charges billed by EWR and will pay invoices within 3 days of receipt of such invoices. If water damage is covered by insurance, EWR will send invoices directly to the invoices directly to the insurance company. Customers may also authorize EWR to perform additional services not covered by insurance in which case EWR will invoice these services directly to the customer. Customer is solely responsible for the charges billed.

Equipment *

• Equipment: EWR will place equipment on site to remove water, moisture and correct water related damage. EWR may also use chemicals to effectively treat damaged areas. EWR shall provide MSDS sheets upon customer request and customer shall immediately notify EWR of any known health or safety issues with the use of such chemicals. Customer will not move, tamper or interfere with EWR equipment. Customer shall keep pets and children away from EWR equipment. Customer shall also take necessary measures to protect EWR equipment from damage or theft. Customer shall promptly notify EWR in the event that equipment fails, malfunctions or appears to not be working properly. Customer holds harmless and indemnifies EWR from liability for property damage or personal injury arising from the use of EWR equipment, materials or chemicals.

Hazards *

• Hazards: Recognizing that drying must be achieved within certain time constraints to be effective and avoid additional damage, customer hereby gives EWR (and its subcontractors) unlimited access to the property to complete the authorized work. Customer understands that an accumulation of moisture in a structure may promote growth of microorganisms which may pose significant health risks to certain individuals. Customer acknowledges that while EWR will make every effort to identify and mitigate existing hazards such as microorganisms or pollutants. EWR does not warrant that the structure is or will be free of such hazards. EWR is not liable for hazards to health or structure caused by microorganisms or pollutants due to the fact that other contributing factors exist outside of the control or influence of EWR. Contributing factors include but are not limited to; temperature, humidity, existing water leaks, insulation of doors and windows, a properly working heating and cooling system, personal lifestyle choices such as smoking, etc. Customer holds EWR harmless for any resulting damage to persons or property caused by such hazards.

Cost Of Drying *

• Charges for drying and demolition will be billed on a time and materials basis calculated by industry standards for the type of work performed. Attached price list is what EWR charges for services, demo and all other items regarding drying structure.

Enforcement of Contract (Judication) *

• This contract, and any amendment thereto, shall be governed by the laws of the State of Georgia. Contract will be enforced only in Jackson County, Georgia. Customer agrees that this will be the proper venue.

Insurance Claims *

• Insurance Claims: If the insurance company pays the customer directly, the customer shall promptly pay EWR for services rendered. If collection efforts are undertaken by EWR, customer agrees to pay reasonable attorney’s fees, court costs and related expenses incurred by EWR in any collection process. Also 1.5 percent interst per 30 days after bill is due. Customer acknowledges that a lien may be placed on the property in the event EWR does not receive timely payment of its invoice.

Customer Signature

Name *

First

Last

Date

Signature

Clear Signature

Employee Signature

Clear Signature

Employee Name *

First

Last

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