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<br />nAil 'A.~ <br /> <br />& <br /> <br />_J~ Mo~~ / P/JID(fIrJtl5/Zf?/tv>d <br />I <br />-:it- Cg71Y- ~ <br /> <br />"rU~.ANC\l <br /> <br />Insured <br /> <br />Claim Number <br /> <br />AUTHORIZATION TO REPAIR - FLORIDA <br />(To Be Signed Prior to Beginning Services/Repairs) <br /> <br />To: State Farm Florida Insurance Company <br /> <br />I have agreed to use the State Farm Premier Se~i~eCll Pro~ram. I understand the use of this program is voluntary <br />and I have been offered the opportunity to choose any independent contractor and/or independent service provider(s) <br />participating in the Premier Service Program. I also understand they are independent contra.Q!ors and/or, independent <br />service providers hired by me and not by the State Farm Insurance. CompaniesCll. I understand State Farm is not <br />exercising its option under the insurance contract to repair or replace any part of the property damaged. <br /> <br />Instead, I have selected and authorize: fNL. WI!' ~a-ctf1~perform repairs as indicated on their <br />estirTlate due to a loss on 57l J f Z7Jf 57. ~ lfttJIdf:f . I understand my dedl;lctible i~ payable <br />to the authorized independ~nt c9.ntractor and/or independent service provider(s) upo~ sa~%.COf1)f)letion of the <br />portion of services or repairs provided in their estimate, or as otherwise agreed ta with State arm Florida Insurance <br />Company. <br /> <br />I agree to pay my independent contractor and/or independent service provider(s) fer any repairs, or additional <br />improvements made at my direction, that are not covered under my policy. <br /> <br />NOTE: For your protection, the law of your state requires the following to appear on this form: Any person who <br />knowingly, and with intent to injure, defraud, or deceive any insurance company, files a statement of claim <br />containing any false, incomplete, or misleading information, may be guilty of a felony and subject to criminal and <br />civil penalties. Violation of this provision is a felony of third dewee. <br /> <br />5-21 <br /> <br />(Date) <br /> <br />2&>3 <br /> <br />(Year) <br /> <br /> <br />This form can not be altered but may be reproduced only by a State Farm Premier St}rviceolll program contractor/servise <br />provider. <br /> <br />10408'\.4 Rev. "\2-"\6-2002 F\oriQa <br /> <br />!~ <br />