FIRST GENERAL CERTIFICATE OF COMPLETION AND DIRECTION OF PAYMENT

I have reviewed all of the work completed by First General (including the work of its subcontractors), an independent contractor provided by my Insurer, that I have elected to use.

I now certify that as of the signing date of this document, this work was completed to my satisfaction and in accordance with the Authorization to Proceed with Work form for the approved insurance loss-related repairs as estimated for the loss location indicated.

I understand that the deductible, if not already satisfied, is my responsibility, as are the costs of any authorized upgrades or additional work which is outside the scope of insurance loss-related repairs.

Direction of Payment

I authorize my Insurer to make payment for the work completed regarding the claim number listed below directly to First General, less any applicable deductible.

Insured Name (required)

Loss Location Address (required)

Claim # (required)

Insurance Company (required)

Date Signed (required) Example Format: 2016-05-30

Your Email (required)

Signature (required, click or tap to draw your signature)