Pure Home LLC

CONTINGENCY AGREEMENT

Property Owner Name *

Property Owner Phone *

Property Owner Email *

Property Address *

Insurance Company

Insurance Company Number

Insurance Company Contact

Date *

Scope of Work *

By submitting this form, the Property Owner(s) authorize Pure Home LLC (the “Company”) to present its findings and scope of work for a project replacement or repair to the insurance company.. When the price from the insurance company is determined, it shall become the final contract price of Insurance Proceeds with no additional cost to the Property Owner(s) except the deductible. If the insurance company denies the claim, this agreement becomes null and void.

 Property Owner accepts the terms and conditions set out on the back for this agreement.

 You may cancel this contract at any time within 72 hours after you have been notified that your insurer has denied your claim to pay for the goods and services to be provided under this contract. See attached notice of cancellation form for an explanation of this right.

Customer Information

Named Insured

Property Insured

Date of birth *

Insurance Co

Home

Auto

Full SSN *

Mr.

Mrs.

Agent

Bank / Mortgage

Loan Number

Year of Construction

Year of Purchase

Construction Type

CLAIM DATA

Policy Number

Effective Date

Expiration Date

Deductible

Claim Number

Claim Type

Cause of loss

Date of Report

Loss Location

Date of Loss

Comments

TEXAS HOME INSURANCE SOLUTIONS

Sales Representative

Team Leader

Insurance Policy *

Home Pure LLC

Pure Home LLC is a McAllen based company that strives to provide RGV residents with financing options for their home improvement needs.

Company Info

Home Pure LLC

Pure Home LLC is a McAllen based company that strives to provide RGV residents with financing options for their home improvement needs.