17 Furler St. Totowa, NJ 07512

Office 877.893.9200 Fax 973.890.0050

AUTHORIZATION FORM

Property Owner
The Palisades Condominium Association / Daniel Ortiz (Property Manager)
Work:(201) 592-6250 Cell: (201) 206-2902
Dominic Farina (Chief Engineer) (201)956-8843
Property Address City State Zip
100 Old Palisade Road Fort Lee NJ 07024
Insurance Company
Chubb Insurance Company of New Jersey /

Claim No 040512128719

Pol No 3592-02-54-FPO /

Claims phone no.

800-252-4670

Deductible $ 10,00000

Adjuster
James (Jim) Gesualdo / Email /

Cell (201) 323-6242 / (908) 903-5438

WeatherTight Rep
Ted Dodson / Email / Cell (954) 478-7890
  1. WeatherTight Systems Inc. scope of work is associated with Superstorm Sandy Related Damages.
  1. Per my responsibility under my insurance policy agreement, I authorize WeatherTight Systems, Inc. to make any necessary TEMPORARY EMERGENCY REPAIRS to the property to ensure a water tight building envelope and to invoice my insurance company for payment of the temporary emergency repairs. Policyholder initials X ______
  1. I authorize WeatherTight Systems, Inc. as my representative contractor to pursue my best interest on the above-mentioned property regarding storm damage and authorize the above-mentioned WeatherTight Rep to contact and meet with my insurance company adjuster to agree upon an acceptable work scope & acceptable pricing.

Policyholder initials X ______

  1. I authorize my insurance company adjuster to send a copy of his estimate to the above WeatherTight Rep and my WeatherTight Rep to send a copy of his estimate to the insurance adjuster in order to facilitate an agreement on an acceptable roof work scope & acceptable pricing. Policyholder initials X ______
  1. If an agreement is not reached by my Insurance Company and WeatherTight, I authorize my WeatherTight rep to pursue all remedies including legal action on my behalf. Policyholder initials X ______
  1. As the work is agreed to by the insurance company I agree to use WeatherTight Systems, Inc.as the contractor for the storm damage restoration on this claim and authorize WeatherTight assignment of benefit of claim. I formally request that all checks issued by the Insurance Company for payment of services list the policyholder and WeatherTight Systems, Inc.as co-payees.

Policyholderinitials X ______

  1. WeatherTight Systems, Inc.agrees that the total cost to the policyholder will be for the deductible amount only. Services will not exceed the total amount allowed by the Insurance Company plus any applicable deductible.
  1. Work will begin only upon approval from the Insurance Company at a date & time agreeable to the Property Owner & WeatherTight Systems, Inc.

Property Owner/Authorized Agent X ______ Board of Directors, President Date______

WeatherTight Systems, Inc. Rep ______Date ______