Hazard Insurance Property Damage Form
Contractor’s Statement
U.S. Bank Home Mortgage account number: ____________________________________________
I, _________________________________________________________________, state that I am a
contractor doing business as ____________________________________________________, whose
address is ________________________________________________________________________.
The undersigned further states that they have been contracted to repair the
_____________________________________________________ damage to the property located at:
________________________________________________________________________________.
It is affirmed that all applicable permits will be obtained.
Contractor’s total bid for repairs: $ ________________________________________________ The
deposit in the amount of $_________________________________________ has/has not been paid.
______________________________________________ __________________________________
Contractor’s SignatureDate
______________________________________________ __________________________________
Business Contact NumbersPermit Required for Job
***Attach copy of Contract/Bid for repairs, license, signed W-9, and insurance
--------------------------------This section is completed by the borrower-----------------------------------
Borrower’s Acceptance of Contract:
___________________________________________ ______________________________
Borrower’s SignatureDate
___________________________________________ ______________________________
Co -Borrower’s Signature |
Date |
Information Authorization:
Information concerning the claim and draw status will not be provided to the contractor unless otherwise authorized by the borrower. Please indicate the information you wish released, by initialing next to your selection.
Note: Account information such as payment status, loan type, etc. is not included within this authorization. Only claim related information would be released if authorized.
_____ Authorization for contractor to request inspections
_____ Authorization to release only claim information
_____ Direct contractor to borrower for all inquiries