Insurance Deductibles

Why It's Important to Pay the Deductible

If you have damage and your insurance policy covers it, you will need to pay your insurance deductible to access further compensation. The deductible will be a fixed amount that you selected when you initially purchased your insurance policy. You are responsible for paying this deductible out or pocket before your insurance company will pay on a claim.

Purpose of Form

You are acknowledging that you understand that you are responsible for paying the agreed upon insurance deductible that was outlined in your policy.

Step 1

Fill in the form below. Remember you can make changes in your dashboard even after the form is submitted. You also have a "Save and Continue at the bottom".

Step 2

After submission check your email for a copy of the PDF agreement that was created from this form. Once fully reviewed, this should be sent to your insurance carrier.

Client Onboarding - Agreement to Pay Deductible

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Client's Loss Information

Insured #1 Full Name:(Required)

Insured #1 Email:(Required)

Insured #2 Full Name:

Insured #2 Email:

Address of Loss:(Required)

Insured Contact Phone Number:(Required)

Date of Loss:

Insurance Company:(Required)

Policy Number:(Required)

Claim Number:

Insurance Carrier Phone:

Default Carrier Claim Email:

Adjuster Contact Name:

Adjuster Email:

Restoration Contractor:(Required)

Contractor Contact Email:(Required)

Contractor Documents Email:(Required)

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Agreement to Pay Deductible

Payment Method

I have been made aware that the deductible is critical to my coverage and initiation of insurance benefits. Therefore, I agree to pay my deductible. I have elected to pay this deductible as follows:

In Full Via Credit Card

In Full Via Check

In weekly installments thru deductible financing organization

In monthly installments thru deductible financing organization

Other

Amount to be paid in Full: One Time Payment

Amount to be paid weekly:

Number of Weeks:

Total:

Amount to be paid monthly:

Number of Months:

Total:

Final Step: Sign & Submit

Insured #1 Signature:(Required)

Date Signed by Insured

Insured #2 Signature (if applicable):

Date Signed by Insured

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Contractor ID