Insurance Remediation Agreement

INSURANCE REMEDIATION AGREEMENT

This Insurance Remediation Agreement ("Agreement") documents authorization, assignment, and the obligations of the Applicant with respect to remediation work relating to an insured loss. Applicant acknowledges that execution of this Agreement constitutes a binding authorization relating to the claim identified below and a certification of facts set forth herein.

Applicant / Insured Information

Applicant Name:   Date of Birth:

Policy and Claim Details

Policy Number:   Policy Type:

Coverage Limit: $   Deductible: $   Premium: $

Policy Period From:   To:

Loss and Remediation Details

Date of Loss:   Time of Loss (if known):

Coverage and Scope of Remediation

Select remediation services authorized under this Agreement (check applicable):

Water damage mitigation and structural drying

Mold assessment and remediation of accessible areas

Fire, smoke and soot cleaning and deodorization

Contents cleaning and pack-out/pack-in services

Sewage and biohazard cleanup requiring specialized handling

Temporary structural stabilization and minor repairs to permit remediation

Other:

Exclusions and Limitations

The following services and conditions are excluded from insurer obligation under this Agreement unless expressly authorized in writing by the Insurer: pre-existing damage and conditions; damages arising from wear and tear, gradual deterioration, or maintenance neglect; concealed contamination beyond accessible areas that require structural demolition beyond that necessary for remediation; hazardous waste disposal requiring specialized licensed hazardous materials contractors; and consequential or punitive damages. Applicant acknowledges that costs arising from excluded items are the Applicant's responsibility unless otherwise covered by the Insurer.

Applicant acknowledges and understands the exclusions and limitations described above.

Beneficiary / Payee Designation

Designated Payee Name:

Relationship to Insured:   Payment Percentage to Payee:

Assignment of Benefits & Payment Authorization

Applicant hereby assigns to the designated payee the right to receive insurance benefits and payments related to the remediation work described in this Agreement, to the extent permitted by the insurance policy and applicable law. This assignment is limited to amounts payable for remediation services and does not transfer any uninsured obligations or policy rights except as specifically stated.

Applicant assigns benefits to the Designated Payee as set forth above.

Authorization to Release Information: Applicant authorizes Insurer and its representatives to release claim and policy information to the remediation provider and designated payee to facilitate inspection, billing, and payment.

Deductible Responsibility (select one):
Applicant will pay deductible amount
Insurer will remit deductible per policy terms
Vendor will apply deductible and seek reimbursement per separate agreement

Documentation Checklist

Documentation provided or to be provided in support of this claim (check all that apply):

Photographs of damage

Estimates from remediation contractors

Receipts for emergency repairs

Required permits or authorizations

Professional inspection or remediation reports

Police or official reports (if applicable)

Release, Indemnity and Subrogation

Release of Liability: Applicant authorizes remediation necessary to mitigate further damage. Applicant acknowledges that remediation may require limited demolition and that the remediation provider will take reasonable precautions. Applicant releases the Insurer and remediation provider from liability for consequential losses arising from necessary mitigation that is within the scope of authorized work.

Indemnity: Applicant will indemnify and hold harmless the remediation provider and Insurer from any third-party claims arising from Applicant's false representations, failure to disclose pre-existing conditions, or failure to secure necessary permissions for work. This indemnity does not limit rights the Insurer may have under the policy to deny coverage for excluded matters.

Subrogation and Recovery: Applicant acknowledges the Insurer's subrogation rights remain intact. Applicant will cooperate with Insurer and designated payee in preservation of subrogation rights, execution of necessary assignments, and provision of documentation to pursue recovery from responsible third parties.

Governing Law and Severability: This Agreement is governed by the law of the jurisdiction where the insured property is located. If any provision is held invalid, remaining provisions will remain in full force.

Certification

By signing below, Applicant certifies that the information provided in this Agreement is true and accurate to the best of Applicant's knowledge, that Applicant authorizes the described remediation work, and that Applicant understands the assignment, exclusions, and indemnity provisions contained herein. Applicant further authorizes Insurer to remit payment consistent with this Agreement to the designated payee to the extent permitted by the policy.

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