Work & Direction Pay Authorization Form

Customer Name:

Contact (Business):

Email Address


Location Of Property:  

Insurance Company:  

Claim Number:  

Job Type:  

Terms and Conditions

1. Invoicing and Payment. Lipscomb Hydra Cleaning Services will submit to Customer or Customer’s insurance company an invoice setting forth the total amount due. LHCS reserves the right to invoice at any of the following times, based on LCHS’s sole discretion: (i) in advance of performance of Work based upon estimates submitted to Customer or Customer’s adjuster or other insurance company representative. (ii) periodically during the progress of Work for any portion upon completion; and/or (iii) upon completion of the Work. Customer also agrees to pay any additional charges incurred for other services performed at Customer’s request not included on any prior estimate or invoice, less previous payments received.  For invoices on portions of the Work priced on a time and materials basis, unit price, or usual and customary charges, the amount due shall be in accordance with Rate Schedule for labor, materials and equipment and subcontract services utilized in performance of the work, until pricing schedule or such other upon receipt of each invoice. Interest shall accrue on payment not received within (20) days from the due date of each invoice at the lesser of (i) the maximum awful interest rate. (ii) one and one-half percent (1 ½%) per month or (iii) eighteen percent (18%) per annum; provided, however, nothing herein shall require the payment or permit the collection of interest in any amount in excess of the maximum permitted by applicable state or federal law in the appropriate jurisdiction.  It is the express intent of all the parties to comply with the applicable usury laws, and the parties agree that any excess interest received shall be credited to Customer’s principal balance or paid, if no balance, upon written notice of such excess payment. In addition to the prices charged, Customer agrees to pay all taxes that may be levied upon or incurred on the above described goods, materials, labor and services by any federal, state or local government and the reimburse LHCS for the amount thereof.

2. Completion Certificates. Customer agrees to inspect Work upon completion or any segment thereof, and Customer agrees to notify LHCS in writing of any claim, damage, defects, deficiencies, or failures in performance with 30 days of the earlier of completion of Work or invoicing or partial performance. To the extent that may validly do so , the parties agree that Work will be deemed to be fully accepted without defect if no notice required herein is received by LHCS within 30 days of completion of Work. Customer agrees to acknowledge in writing completion of Work that has been performed satisfactorily upon request by LHCS.

3. Arbitration. The parties agree that any controversy or claim arising out of or relating to this Authorization, the services of LHCS, damages of breach by LHCS shall be settled by arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association, and judgment upon the award rendered may be entered ONLY IN A DAVIESS COUNTY, KENTUCKY COURT HAVING JURISDICTION OVER SUCH CONTROVERSY OR CLAIM.  However, any action solely for collection of amounts due LHCS by Customer any be brought in state court without first going to arbitration, but any other claims, including counterclaims, shall be referred to arbitration. Any and all claims or cause of action against LCHS shall be submitted prior to two (2) years from completion of the work by LHCS or be barred, irrespective of any other applicable stature of limitation.

4. Storage Agreement. Customer authorizes LHCS to store all items removed from Customer’s Property, and to charge Customer at LHCS current storage and handling charges, together with other expenses reasonably incurred in the moving, storage, handling, and preservation of the stored items. LHCS will issue to Customer a general inventory of the items received (generic description of large items and the designated number of each box of property). LHCS shall not be responsible for describing each item stored or items left at Property. Prior to beginning any work on the Property. Customer shall be responsible for removal of all jewelry and watches; cameras and photographic equipment; coins, cash and money; collections and valuable collectibles; valuable painting, sculptures, and artwork; checks and checkbooks; guns, firearms, ammunition or explosives; chemicals, pesticides, petroleum products; etc. Customer shall take appropriate steps to secure these items elsewhere, even if other items are cleaned on-location. LCHS will not be responsible for any damage to or the removal, packing or storage of these items or any items that are left on the Property by LHCS, whether or not such items are capable or being cleaned and restored. If Customer desires to keep any of the totaled items or the items not taken to LHCS, it shall be Customer’s sole responsibility to safeguard, remove and store such items. LHCS shall not be liable for any damages, loss, or injury to the stored items other than such as is caused by LHCS’ failure to exercise such care in regard to such items as a reasonably careful person would exercise under like circumstances. IN NO EVENT SHALL LCHS BE LIABLE FOR ANY LOSS OF OR DAMGES TO STORED ITEMS IN EXCESS OF THE AMOUNTS PAID TO (LHCS) FOR STORAGE OF THE PARTICULAR LOST OR DAMAGED ITMEM. CUSTOMER HEREBY GRANTS TO LCHS A LIEN ON ALL ITEMS STORED BY LCHS TO SECURE PAYMENT OF THE STORAGE, TRANSPORATION, INSURANCE, LABOR, WORK, AND OTHER SERVICES OF CHARGES ON ANY OF THE ITEMS STORED, AND FOR EXPENSES NECESSARY FOR THEIR PRESERVATION OR REASONABLY INCURRED IN THEIR SALE PURSUANT TO EFORCEMENT OF A WORKER’S AND WAREHOUSMANS’S LIEN ON SUCH ITEMS. In addition, LHCS shall have all remedies available to it under applicable state or uniform laws for enforcement of such worker’s and /or warehouseman’s lien.

5. Entire agreement and Authority. The terms and condition herein and those referenced in any scope submitted shall be deemed to be accepted and agreed upon by Customer, to the exclusion of any terms or conditions, by Customer’s signature on this Authorization. This Authorization and any scope and/or documents referenced herein comprise the Agreement of the parties respecting the Work and services to be performed. No other engagements, promises, representations, guarantees or warranties have been made or should be relied upon by either party except as is expressly stated in this Authorization, Scope of Work, or other documents reference therein in writing. No representative of LHCS has authority to alter the terms and conditions referenced herein without the written approval of an officer of LHCS. If Customer or the party signing this Authorization is someone other than the owner of the Property, then they represent that they have full authority from the owner of the Property or customer to enter into the terms of the Authorization and are acting with such authority by executing this Authorization or will be fully liable and responsible if acting without proper authority.

6. Miscellaneous. No waiver by LHCS with respect to any breach or default or any right or remedy shall be deemed to constitute a continuing waiver of any other breach or default or of any other rights or remedies, unless such waiver is expressed in writing and signed by LCHS. Should LHCS be required to bring any action or arbitration to enforce the terms of this agreement or collect any amount due LHCS, then LHCS shall be entitled to recover from Customer all reasonable costs and expenses in collecting, suing or arbitrating this matter, including attorneys’ fee. The terms and condition of this Agreement shall inure to the benefit of and be binding upon the parties hereto, their respective heirs, representatives, successors and permitted assigns. Any document transmitted by facsimile machine (“fax”) or other electronic means after being executed either manually or by other electronic means shall be treated for all purposes as an original document. The signature of any party on a document transmitted by way of a fax machine or signed by electronic means shall be considered for all purposes as an original signature. Any such document shall be considered to have the same binding legal effect as an original document.

By signing below, Customer hereby instructs Customer’s insurance carrier to pay dicretly to LHCS (excluding Customer’s name from the draft) any balance due for services rendered, emergency or otherwise, less any deductible actually collected from customer. Customer does hereby transfer and assign to LCHS that portion of the proceeds payable from Customers insurance policy covering the loss or any damage to Customer’s property, in the amount equal to the charges for the services rendered and/ or to be rendered by LHCS on the Property. Customer understands and agrees that the customer shall remain primarily and fully responsible for payment of all sums owed to company for any services provided which are not paid by Customers policy, regardless of the reason for nonpayment, and agrees to make such payment in Customer’s insurance fails to make timely payment in accordance with the terms and conditions on the back of this Authorization. All amounts specified above shall be solely for the Work, and any additional services provided shall be subject to additional charges in accordance with the usual and customary rates & fees charged by LHCS. All payments are payable to LHCS’ representatives or at LHCS address as set forth above and are due upon the receipt of invoice or completion of Work, whichever occurs first. LHCS reserves the right to submit and Customer agrees to pay periodic invoice during progress of the Work for the completed portions of any work.

Customer authorizes the Work and agrees to term of conditions set forth on both sides of this Work Authorization, any Scope of Work covering the Property; any other document referenced in such documents, which are incorporated herein and make part of this Authorization. The terms and conditions on both sides of this Contact shall govern all labor, materials, rentals, & services furnished by Lipscomb Hydra Cleaning Systems to Customer in this authorization and any subsequent services provided to Customers pertaining to the property, whether or not subsequent Authorization, Scope or other agreement is actually signed.

Lipscomb Hydra Cleaning Systems, LLC
P.O. Box 111
Philpot, KY 42366

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Signed by Stuart Lipscomb III
Signed On: May 12, 2021

Signature Certificate
Document name: Work & Direction Pay Authorization Form
lock iconUnique Document ID: af49c5ce29ab015b9c9f6158f643eecfecf5fb11
Timestamp Audit
April 19, 2018 1:40 pm EDTWork & Direction Pay Authorization Form Uploaded by Stuart Lipscomb III - IP,,,