Private Client Group - Hurricane Protection Unit

AUTHORIZATION FORM

I am the owner of the residence indicated below, and I have a homeowners insurance policy covering this residence through Private Client Group. I hereby authorize vendors of my insurance company (the “Service Providers”) to assess the exterior of my property and provide short-term repairs after a hurricane has damaged my property (the “services”). The intent being that these services may reduce the risk of further loss or damage to my property.

I understand that once I sign this authorization, the Service Providers may access the exterior of my house at any time after a hurricane in order to provide the services.

I understand and acknowledge that the services provided by the Service Providers may not prevent damage to my property or residence. I also understand that there is no guarantee that the Service Providers will be able to provide the services to my property. I AGREE THAT THE SERVICES PROVIDED ARE “AS IS” AND THAT MY INSURANCE COMPANY AND THE SERVICE PROVIDERS SPECIFICALLY DISCLAIMS ALL WARRANTIES TO THE SERVICES EXCEPT AS SPECIFICALLY STATED HEREIN.

I understand that as a policyholder I will not be charged for this service; the Hurricane Protection Unit will submit a claim on my behalf to cover the fees for this service. The claim will be coded as catastrophe related so there will be no adverse rating in my claim history. Private Client Group has the right to terminate this service at any time and for any reason. I understand that this service will automatically terminate if I am no longer a policyholder. I also understand that my participation is totally voluntary.

All fields are required.

By checking this box, I hereby agree to the above terms.

NOTE: This service is only available to policyholders residing in one of our pre-approved coastal counties. Policyholders in Florida must also have wind coverage to be eligible.

Title

First name

Last name

Street address:

City:

State:

Zip:

This information will only be used by Private Client Group and only for the purposes of contacting you during an emergency situation. We will not use or share this information for any other purpose other than for this program.

Please provide at least one phone number where you can be reached in an emergency:

Required: (Numbers only; no special characters)

Additional contact numbers, if applicable: (Numbers only; no special characters)

Email address: (An email confirmation will be sent to this address)

Alternate contact person during an emergency:

Phone:

Access/gate codes:

I’d like to receive a complimentary disaster preparedness assessment to help me determine if I need to better prepare my home and my family for disaster. Please contact me to set up a consultation.
Yes No

Contact person for non-emergency related issues including complimentary onsite consultation:

Name:

Phone:

Relation:

Do you wish to receive non-emergency email updates from the Hurricane Protection Unit?
Yes No

Insurance agent: