Certified Flooring Network

Insured’s Name: __________________________________________________ Claim#____________________ Address: __________________________________________________________________________________ City: _______________________State:____________ Zip: _____________ Contact Phone: _______________

I, (Insured’s Name) ___________________________________the undersigned, authorize (Flooring Provider Company Name)

____________________________________, hereinafter referred to as “Contractor” to remove samples for Like, Kind & Quality (LKQ)

analysis.

______________________________ _______________________ (Insured’s Signature-required) (Date) _______________________________ _______________________ (Insured’s Signature) (Date) _______________________________ _______________________ (Flooring Providers Signature) (Date) To: ________________________ (Insurance Company Name) I understand that this “Authorization to Pay” extends solely for the services or repair expenses covered by my insurance policy as a

result of the above named loss. I understand that my deductible amount is $_______________and I agree to pay that amount directly

to _____________________________(Flooring Provider Company Name), I understand that I may upgrade my flooring materials and I

agree to separately pay and be liable to the contractor for any services, repairs or additional improvements made at my direction that

are not covered under my insurance policy.

I authorize payment on my behalf to Certified Flooring Network ™ in the above referenced claim for the amount shown on the final

estimate(s) or invoices sent to the Insurance Company by the above named I authorize any/all supplements payable directly to Certified

Flooring Network. I do hereby appoint Certified Flooring Network™ to act as Power of Attorney in fact to accept on my behalf any and

all checks, drafts, or bills of exchange, and to endorse all such checks, drafts, bills of exchange for deposit to Certified Flooring Network’s

account for services rendered.

My signature below indicates my agreement that the Flooring Provider named above is authorized to perform repair or replacement

services on my property.

Insured’s Signature) _________________________________________ (Date) ___________________

(Printed Name)________________________________________________________________________

588 Nashville Pike. Gallatin, TN 37066 T: 615-230-5966 F: 888-873-3619

www.certifiedflooringnetwork.com info@certifiedflooringnetwork.com CONFIDENTIAL - FOR INTENDED RECIPIENT USE ONLY ©2016/CFRN™, All Rights Reserved. (06.2016)

PART A Flooring LKQ Sample Collection

DEDUCTIBLE $ ____________________

(required at time of Product Selection)

PART B Work Authorization Form

PLEASE READ EACH SECTION CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE CALL:

1(888) EZ1-CLAIM/ (888) 391-2524