Contractor Name:

________________________________
Address: ________________________________
Phone: ________________________________
Email: ________________________________
EIN : ________________________________

FINAL COMPLETION / INVOICE

Insured / Customer: _______________________________ Home Phone: _________________________

Property Address: _______________________________ Cell Phone: _________________________
_______________________________ Other Phone: _________________________
Billing Address: _______________________________ Primary Email: _________________________
_______________________________ Secondary Email: _________________________

Insurance Company: _______________________________ Policy Number: _________________________

Claim Number: _______________________________ Completion Date: _________________________

Description of work completed: ___________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

Claim TOTAL: ____________________

Sales Tax: ____________________
Final Invoice TOTAL: ____________________
* Payment due in full upon job completion

I hereby certify that all replacement work related to this claim has been made in a satisfactory manner for the
above mentioned property. The policy holder, property address, claim number, completion date, and material used
are all listed above.

____________________________________ ______________________________
Authorized Signature Date
(Contractor Name)