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Blank Texas Pc068 PDF Template

The Texas PC068 form is a certification document designed for residential property owners seeking a reduction in their insurance premiums. By completing this form, homeowners can certify that their roofing installation meets specific standards, thereby qualifying for potential savings. It is important to note that this certification does not imply any warranty from the roofing manufacturer, supplier, or installer.

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Contents

Form Example

PC068 | 0423

Impact-Resistant Roofing Installation Form

Notice to Homeowner

This form can show that a property has impact-resistant roofing. Some insurance companies may offer an insurance premium discount for buildings with impact-resistant roofing. This form is not to be construed as any type of express or implied warranty by the manufacturer, supplier, or installer. Property owners should keep the original and send a copy to their insurance company.

Roofing Company Information

Name

Address


City	State	ZIP
Phone

Property Information

Name

Address


City	State	ZIP
Phone

Manufacturer Information

Manufacturers’ name

Brand name

Year manufactured

Installation date

Labeling of products - the roof covering installed on the property listed above has the following labeling. Read the statement below and mark the checkbox if true:

The roof covering product packaging indicates the U.L. classification under U.L. Standard 2218, the manufacturer’s name, the date of manufacture, and the brand name. A label from the packaging was given to the owner of the property.

Texas Department of Insurance | www.tdi.texas.gov

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Certification

I,			, an authorized representative of
		roofing company, do hereby certify that

I installed the roof covering on the property listed above according to manufacturer specifications. The roof covering is listed as complying with Underwriters’ Laboratory Standard 2218, Impact Standard for Impact Resistance of Prepared Roof Covering Materials, and has an impact resistance Classification of:

Class 1	Class 2	Class 3	Class 4

Roofing Company Representative Signature				Date

Texas Department of Insurance | www.tdi.texas.gov

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Affidavit of Heriship - If there is a surviving spouse, they usually have the authority to complete the form alone.

Common mistakes

Failing to provide complete information about the roofing company, including the name, street address, and license number if applicable.
Not including the correct address of the residence where the roofing installation took place.
Leaving out the date of installation, which is crucial for verifying the roof's compliance with insurance requirements.
Neglecting to check the appropriate labeling of products section, which confirms the U.L. classification of the roof covering.
Providing an incorrect classification for the impact resistance of the roof covering, which can lead to issues with insurance eligibility.
Forgetting to obtain the original signature of the roofing company’s authorized representative, which is necessary for the form’s validity.
Not retaining a copy of the form for personal records, which is important for future reference and potential claims.
Submitting the form without ensuring that all information is accurate, as any misrepresentation can be considered fraud.
Failing to provide the contact information for the homeowner, which is needed for communication regarding the insurance premium reduction.

Key takeaways

Here are some important points to keep in mind when filling out and using the Texas PC068 form:

Purpose: This form is designed to help homeowners receive a reduction in their residential insurance premiums.
Roofing Company Information: Make sure to fill in the roofing company's name, address, and contact details accurately.
Owner's Information: The homeowner's name, address, and phone numbers must be clearly provided.
Certification: An authorized representative from the roofing company must sign the form to certify the installation.
Impact Resistance: The roof covering must comply with Underwriters’ Laboratory Standard 2218 for impact resistance.
Labeling: Ensure that the roofing materials are properly labeled with the required information, including the U.L. classification.
Copies: Keep one copy of the completed form for your records and send another to your insurance company.
Fraud Warning: Be aware that any false information on this form can be considered fraud.

⇓ Texas Pc068 PDF

Steps to Using Texas Pc068

After completing the Texas PC068 form, you will be able to submit it to your insurance company to receive a reduction in your residential insurance premiums. Ensure that all information is accurate and complete before sending it off.

Obtain the Texas PC068 form from the Texas Department of Insurance website or your insurance provider.
Fill in the Name of Roofing Company at the top of the form.
Provide the Street Address, City, County, Zip Code, and Phone number of the roofing company.
If applicable, enter the License Number of the roofing company.
In the section for the Address of Residence, fill in the Name of Owner, Home Phone, Office Phone, City, County, and Zip Code.
In the certification section, the authorized representative of the roofing company should fill in their name.
Indicate the impact resistance Classification of the roof covering installed (Class 1, Class 2, Class 3, or Class 4).
Provide the Manufacturers’ Name and Brand Name of the roofing material.
Enter the Year Manufactured and the Date of Installation.
Check one of the options regarding labeling of products to confirm compliance with U.L. Standard 2218.
Ensure the Original Signature of the roofing company’s authorized representative is included along with the Date.
Make copies of the completed form: one for the homeowner and one for the insurance company.