Authorization to Process and Direction to Pay

I authorize Embassy Cleaners to remove item from my home for the purpose of cleaning, and/or perform on-site cleaning services. These items may include wearing apparel, bedding, linens, footwear, window treatments, upholstery, rugs/carpets and other items I direct Embassy to remove and/or clean on site. I understand that Embassy Cleaners will, to the best of its professional ability, work to clean these items with the goal of restoring them to their previous condition. I also understand that Embassy Cleaners will charge rates for their services that are within the usually accepted range of pricing for cleaners in this area. I further understand that, due to the water and or smoke event incurred, irreparable damage may have been caused to my items, such as permanent staining and shrinkage, and that I/we do not hold Embassy Cleaners responsible for causing this/these conditions.

Acknowledgement *

In the event the insurance carrier remits payment directly to me, I agree to remit said payment directly over to Embassy Cleaners, located at 826 Scarsdale Avenue, Scarsdale, NY 10583 within 7 days of receipt or insurance payment. In any event, I accept full responsibility for payment of Embassy’s services rendered.

Insurance Authorization *

I further authorize my insurance carrier, to pay Embassy Cleaners directly for services rendered. (Self Pay, Select as Well)

First Name *

Last Name *

Phone *

Email *

Insurance Carrier (If self-pay click "Other") *

Other Insurance

Claim Number (If Available)

Adjuster Name (If Available)

Signature *

Clear

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