How to fill out this form.
  1. Click the "" button to print a copy for each contractor.
  2. Ask each contractor to complete and sign form.
  3. The dollar amount on this form must match the dollar amount on the contractor's contract.
  4. Upload, fax, or mail the form to us.
  5. Any correspondence/contact about this claim will be directed to you or authorized third party.
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(SOMECITY, ZZ 00000-1111)
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Conditional Waiver of Lien

(To be Completed by Contractor(s))

Date:

Loan Number:

Mortgagor(s): (#000000)    (#000000)

Mortgaged Property:(#000000)

Servicer: Insurance Claims Center

Date of Loss:

The undersigned on behalf of the named contractor ("Contractor") has entered into a contract ("Contract") to complete the repairs as described in the Contract to the above identified Mortgaged Property owned by the above Mortgagor(s) ("Work").

Contractor agrees, represents and warrants to the above Servicer and Owner(s) that:

  1. A true copy of the fully executed Contract is attached and provides that the Work will be performed by Contractor for $;    (Attach copy of signed contract.)
  2. Contractor has received a deposit in the amount of $ toward payment of the contract;
  3. Permits (check one)
    • are
    • are not
    required to perform and complete the Work. If required, copies of all required permits are attached;
  4. All Work will be completed in a workman-like manner and within industry standards by competent and experienced personnel;
  5. When completed, the Work will restore the Mortgaged Property to at least its condition prior to any damage or loss;
  6. Contractor will comply with all applicable laws, regulations and ordinances, including but not limited to obtaining all required permits, inspections and approvals;
  7. Upon completion, and prior to final payment for the Work:
    • Contractor will have fully paid for all materials, labor, tools, equipment, construction facilities and everything of every sort furnished by it, or by its subcontractors or material men, upon the Mortgaged Property and furnished for the Work, and
    • Contractor must provide a properly executed Waiver of Mechanic's Lien in recordable form, to the Owner and Servicer.
  8. Contractor's business or license number is , and a true copy is attached.

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