Insured's Name
Insured's Address:
Claim:

I/We hereby authorize Ash Services Ltd. to perform all necessary repairs and restoration work (the “Repairs”) to the building and premises located at:
Cause of Loss:
The repairs are to include:Emergency clean up or repairCleaning and restoration of contentsStructural repairs

I/We (the undersigned) Acknowledge and Agree to the Following Terms and Conditions:
Ash Services Ltd. is hereby authorized to commence the Repairs on the Property.
I/We agree that the payment of any insurance deductible (if applicable) is hereby payable to Ash Services Ltd.I/We agree to pay interest on overdue invoices at the rate of 18% per annum (1.5% per month) Ash Services Ltd. may disclose personal information necessary for the completion of the Repairs to insurance adjusters and agents, insurance companies, engineers, sub-trades, material suppliers, service providers, any agencies retained for collection ofoutstanding accounts, Federal, Provincial and Municipal authorities and others as deemed necessary.
I/We hereby give consent to such disclosure in accordance with the provisions of the Personal Information Protection and Electronic Documents Act and the Personal Information Protection Act.
I/We acknowledge and agree that certain dangers and hazards exist on a work site. I/We hereby waive, release and discharge Ash Services Ltd. and its employees, agents and sub-trades from any liability for personal injury, death and any other damaged wherever or however caused.
Ash Services Ltd. is hereby instructed to direct the invoice(s) to the appropriate insurance representative and shall be paid directly the full invoice amount within 30 days from the date of the invoice(s).
I/We acknowledge and agree that if for any reason my/our insurance company should deny payment for the invoice(s) or any portion thereof that I/we will be liable to Ash Services Ltd., jointly and severally, for payment of the same and I/we will pay the invoice(s) within 30 days from the date of the invoice(s).
I/We agree that if I/we are register with a G.S.T. number we will pay the G.S.T. portion of my/our claim as set out on the invoice(s) directly to Ash Services Ltd. within 30 days from the date of the invoice(s) as we may be entitled to a G.S.T. refund from the government.
I/We irrevocably authorize my/our insurance company to pay all amounts invoiced directly to Ash Services Ltd. I/we further irrevocably assign to Ash Services Ltd. all insurance proceeds in relation to the Repairs.
I/We agree that any extra materials and/or labour requested and which are not covered by insurance will be paid by the undersigned within 30 days of the invoice(s) and is subject to the contractor’s usual overhead and profit.

Date:
Authorized Title
Name