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60 RAYNOR AVENUE, RONKONKOMA, NY dvffOlk (68T) AM,31a1
117'79 ~aa• 1516) 2.O8T•
CERTIFICATE OFAUTg0R1ZATtON i 0411 4n-
NAME 1
DAM OFLQS4
JOB ADDRPSS
J) ( RTh S+c,r
TOWN & STA7EItIid)k~. 1?J kn3
T (we) Qkreivafler nfima to u the "CUstoncr") hereby audwdr
e AI !Y.ANDrR WALL CORFORATiON
aim refua o es the oraatoV') to Prod with the Ito„ work required as a result of
aAao
the
ALEXANDER WALL CORPORATION personncj will
attempt to restore all an= to
be e for any items that raaaot be restored due totheir conditloij Ito
the nature and
For wined recaved,
Cam, does hereby ably assign to ALEXANDER WALL CORPORT'fOl~i,
WEs or Avetuze, Ronleoo SW York 11779, any and all sum
dueto him from the or wets of money now due or to become
wade p4aemt >wwa~ ►bar the
m*r hereby authorizs *o
Cmetrattor to negotiate with Customer's Isuuatua
ender to settle this claim for by company his behalf in
services~
for said services, Customer ikMhar and AL 4N WALL CORPORATION ~ obtain
dedecribles and depicciatlog, an well many other ch and arm that he is personally Babe. (or
arges not covered by his Insurance. any and all
Cu mo er reP 'a that he Is the mid ' or the authorized agent of the record owner of the above.
deem m has full qty to enter into this agreement.
that his insurance policy was in full woe and c ct
dateoflem that the Coverage provided byper's on the
suited; that r dt the awed lm t to oovef the cost of repair of the lass
' nor r0 proceeds due a5 a result of the subject loss have
beenaesianed.
UJ ie' hereby acknowledges thu he
has read this c:antrarx in itA entirety, iedumng
and isIn ftifl agreement with the t5ft15 and the back page berwf,
coedtiom as stated thereon.
Customer's Sigeature
By
NYC-WTC 000131075
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NYC-WTC_000131075Source: NYC Law Department, mirrored locally