THE INSURANCE COMPANY IS
HEREBY AUTHORIZED TO PAY MY CLAIM IN THE SUM OF:

DIRECTLY TO MasterDry, LLC (Tax ID 41-2063895) | 28 Ceramic Drive, Martinsburg, WV 25405

FOR REPLACING AND/OR REPAIRING MY PROPERTY MADE NECESSARY BY THIS OCCURRENCE WHEN THOSE REPLACEMENTS AND REPAIRS HAVE BEEN COMPLETED.

Insured Signature:

Date: