Release Of Liability Release Of Liability And Waiver Of Claims

ADVERTISEMENT

Release of Liability
Release of Liability and Waiver of Claims
Health and Safety Assessment
In addition to the energy audit we will do on your home, we will also do a limited health and safety assessment of
the home. The health and safety assessment will consist of a visual inspection for potential health and safety
problems. You will be notified of any health and safety problems that are identified, including mold. However, the
evaluator is not a qualified mold professional. Mold may be present in areas not accessible or seen during the
visual inspection or during the actual work on your home. Work on your home will be performed in a manner to
prevent future mold growth. However, if there are existing conditions that are unseen or if, after the work is
completed, situations within your home result in mold growth, we shall not be held responsible or liable.
Weatherization Activities
N otice: During weatherization activities, particularly when insulation is being blown into wall cavities and attics,
insulation dust, other types of dust, and other particles may become airborne. Additionally, unforeseen
circumstances may result in some insulation leaking through cracks into the home’s living space. In those
circumstances where insulation leaks into the living space, we will be responsible for clean-up (repairing damage
and cleaning up the living area). Minor construction dust is inevitable at the end of any remodeling work.
Construction dust clean-up will be the responsibility of the home owner/occupant.
Recommendation: Does anyone in the home have any of the following conditions:
Allergies
Yes
No
Pregnancy
Yes
No
Asthma
Yes
No
Other Respiratory Conditions
Yes
No
Emphysema
Yes
No
Decreased Immune Functions
Yes
No
It is recommended that people with the above health conditions be out of the house when insulation is being blown
into the house. Furthermore, it is also recommended that infants less than 12 months old should be out of the house
when insulation is being blown. Persons who leave the house during the insulation process should remain away
from the house the amount of time specified in the manufacturer’s instructions.
Release and Waiver of Claims:
I acknowledge by my signature below receipt of the information and
recommendations set out above. Additionally, I agree on behalf of myself and any minor children or others for
whom I am responsible, to hold the agency and its agents harmless from any claims, medical problems or personal
injuries that may occur, develop or worsen in response to the weatherization activities. This waiver is for all
damages, direct or indirect, that may relate to weatherization activities, including money lost by not being able to
work, healthcare costs and pain or suffering.
I am aware the weatherization process may cause airborne particles, including dust, to be released in my
home and that such airborne particles can aggravate health conditions in some people. I have chosen to go
forward with the weatherization process, accepting any and all risks of injury or damages.
I have carefully read this release and waiver and fully understand its contents. I am aware this is a release of
liability and have signed it of my own free will.
Client Name: ____________________________________________________________ Phone: ________________________
Address: ______________________________________________________________________________________________
City, Zip: __________________________________________________________ File Number: ________________________
Client Signature: __________________________________________________________ Date: ________________________
Agency Name: __________________________________________________________ Phone: _________________________
Agency Representative Signature: ____________________________________________ Date: _________________________
Original – Agency File (always)
10-01-12
Copy – Client (always)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go