HomeMy WebLinkAboutOceanside Restoration Authorization 11-02-2018 THE RIGHTCHOICE
Since 1971 (Mee only a' t
ceanside.
Restoration
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217 Thornton Drive,Hyannis,Mass.02601
508-771-3110
800.464-3318(MA.Only),774.470-2211 Fax
ASSIGNMENT AND AUTHORIZATION TO PAY
The undersigned, herein called claimant, has authorized and ordered
from Oceanside, Inc. , the materials and/or services requested.
Undersigned hereby assigns to Oceanside, Inc. any unpaid proceeds due
or to become due, under the claimant 's policy with the insurance
company to pay direct to Oceanside, Inc. or to include its name on a
check or draft, for all requested work.
In the event that Oceanside's claim herein is not covered by, or paid
by, an insurance company, claimant agrees to pay Oceanside, Inc. within
sixty (60) days after work has been completed.
Claimant understands that Oceanside, Inc. is working for them and not
the insurance company or the adjuster.
Payments remaining due and payable after the claimant has received
payment from the insurance company shall bear interest at one and one-
half (1-1/21) percent per month.
In the event that there is a breach by the claimant of any of the
conditions of this agreement, Oceanside, Inc. shall be entitled to
recover, as additional damages, attorneys ' fees, costs and any other
collection expenses reasonable and attributable to said breach. If
payment is not received within 60 days, collection action will commence
without further notice to the claimant.
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LOSS/DAMAGE ADDRESS
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MAILING ADDRESS (BILLING) CITY TATE ZIP
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INSURANCE ADJUSTER' S NAME/CO. LOCAL INSURANCE AGENCYgME
PRINT NAME INS. CARRI POLI UNDERWRITER
DATE: t \ 213
CLAIMANT'S SIGNATURE
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