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303-286-9094
DS ENVIRONMENTAL
Work Authorization and Direction of Payment Contract
Property Owner or Representative
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Service Address
(Required)
Street Address
Unit/Apt #
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Different Mailing Address?
(Required)
No
Yes
Mailing Address
(Required)
Street Address
Unit/Apt #
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Authorization of Services
Date of Service
(Required)
MM slash DD slash YYYY
Description of Services
(Required)
Asbestos Testing
Lead-based Paint Testing
Mold Testing
I Don"t Know
Other
Select all that apply
Description of Other Services
Brief Description
Authorization
(Required)
I agree
By checking this box, I authorize DS to perform all necessary building inspections, environmental consulting, and industrial hygiene services and submit any samples for laboratory analysis at the service address, even if those services are not specified above or were requested by another party, such as a remediation company.
I also understand and acknowledge that the collection of asbestos samples is a destructive process. By checking this box, I authorize DS to perform this sampling and agree that DS will not be responsible for repairing any resulting damage to building materials, and DS cannot be held liable for this damage.
If inspections services occur outside of normal weekday business hours, additional after-hour inspection fees may apply.
This Authorization shall remain in effect and apply to the initial services described herein, as well as all subsequent site visits, supplemental inspections, and any modifications to the scope of work associated with this project until its completion. Client acknowledges that future services related to this project, even if different in nature from the initial inspection, are governed by the terms and conditions of this agreement.
Payment Terms & Authorization
Direction of Payment (Select One)
(Required)
Bill Direct - I will work directly with DS regarding payment.
I agree to either pay in full at the time of services are performed, or I agree that I will pay the invoice in full within 30 days of receipt. A service charge of $50.00 and/or 1.5% interest will be assessed for each 30-day period after the invoice is past due. At 90-days delinquency of overdue accounts, DS reserves the right to place a mechanics lien on the property and pursue further means of collection. All collections charges, legal fees, and court fees incurred by DS will be charged back to the client.
Bill Insurance Directly - I have authorization to request DS bill my insurance company directly for the services performed. I authorize my insurance company to pay DS directly for the services performed. If the insurance company fails to pay DS, I understand that after 30 days, I am responsible for the entire past-due amount. If the insurance company pays me for DSs services, I shall remit any/all past-due amounts paid to me upon receipt. A service charge of $50.00 and/or 1.5% interest will be assessed for each 30-day period after the invoice is past due. At 90-days delinquency of overdue accounts, DS reserves the right to place a mechanics lien on the property and pursue further means of collection. All collections charges, legal fees, and court fees incurred by DS will be charged back to the client.
Insurance Company & Claim Information
(Required)
Insurance Company
Claim #
Adjuster Information
(Required)
Adjuster Name
Adjuster Email
Adjuster Phone
Acknowledgment
(Required)
I agree
By checking this box and submitting the information contained in this form, you are granting us permission to proceed as directed. You acknowledge that you have read, understand, and agree to the Payment Terms. Your information is secure and will not be shared with any other party. Submitting this form will NOT enroll you in any email subscription services.
Name
(Required)
Full Name
Date
(Required)
MM slash DD slash YYYY
Authorization Signature
(Required)
A signed copy of this Work Authorization form or any other ancillary agreement transmitted by facsimile, email, or other means of electronic transmission shall be deemed to have the same legal effect as delivery of an original executed copy of this Work Authorization or such other ancillary agreement for all purposes.
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