Stone Construction Services

111 Ocean Avenue

Camas, WA 98607
(900) 555-1111
WA License #STONECS000W

Insurance Proceeds Agreement

Date: 11-22-12

Agreement for Payment for Itemized Written Price Quotation for Repairs to the Home
(Building) at:

1234 W. Hill St., Camas, WA 98607

STONE CONSTRUCTION SERVICES has provided an itemized written price quotation to the
home/building Owner for the repair of damages to the home (building) as a result of:

A fire on November 19, 2012

It is agreed between the parties that for providing this itemized written price quotation the
Owner agrees to pay STONE CONSTRUCTION SERVICES the sum of $ 1,290.00 .
Payment will be due within three (3) working days of the negotiated settlement between the
Owner and the insurance carrier or carriers, or any other parties in any litigation pertaining
to this matter, or within 2 months or 60 days of the date of this agreement, whichever comes
first.

If Owner does not pay STONE CONSTRUCTION SERVICES as per this agreement, Owner
understands and agrees a Lien (may/will) be filed against the property.

If STONE CONSTRUCTION SERVICES is contracted to repair the entire quoted damages,

the $ 1,290.00 will be applied to the contract price for this job.

John Q. Smith 11 / 22 / 12
(Owner) (Date)

Mary I. Smith 11 / 22 / 12
(Owner) (Date)

1234 W. Hill St. Camas, WA 98607

(Address) (City, State, Zip)

STONE CONSTRUCTION SERVICES 11 / 22 / 12

(Company) (Date)