Your Company Name
Your Address
Your Phone Number
Your Web Address
CONTRACT FOR SERVICES, ASSIGNMENT OF BENEFITS, DIRECT PAYMENT AUTHORIZATION, AND
HOLD HARMLESS AGREEMENT
W W W. C O H E N B AT T I S T I . C O M
I, the Owner/Agent for the job site listed below, authorize (Insert Your Company Name) (hereinafter referred to as
“Company”) to enter my property, furnish materials, supply all equipment and perform all labor necessary to preserve and
protect my property from further damage.
ASSIGNMENT OF INSURANCE BENEFITS
I, hereby, assign any and all insurance rights, benefits, proceeds and any causes of action under any applicable insurance
policies to Company, for services rendered or to be rendered by Company. In this regard, I waive my privacy rights. I
make this assignment in consideration of Company’s agreement to perform services and supply materials and otherwise
perform its obligations under this contract, including not requiring full payment at the time of service.