In the intricate landscape of insurance claims, the Clearwater Public Adjuster form presents a crucial document, delineating the formal agreement between an insured party and Lighthouse Public Adjusters, Inc. By entering into this agreement, the insured person engages Lighthouse Public Adjusters, Inc. to represent them in the negotiations for their insurance claim, following loss or damage caused by specified perils. This comprehensive document carefully outlines the terms under which the firm will operate, specifying a percentage fee that will be drawn from any settlement proceeds from the claim. Additionally, the agreement details responsibilities including but not limited to the authorization for the insurance company to issue payment directly to the adjusting firm, the establishment of a lien on recovered proceeds in favor of the adjuster, and a clause on the potential engagement of additional services such as attorneys or appraisers if necessitated by the complexity of the claim. Furthermore, the form takes into consideration scenarios such as misrepresentation by the insured, cancellation rights, and the binding nature of the agreement even in the event of the insured's death, thus ensuring that both parties are equipped with a clear understanding of their commitments. The inclusion of a clause regarding litigation ensures that any disputes will be resolved within Miami-Dade County, Florida, underscoring the importance of location in legal proceedings. By signing this document, the insured verifies the accuracy of the provided information and acknowledges the terms of engagement with the Lighthouse Public Adjusters, thereby formalizing the professional relationship critical to navigating the often tumultuous process of insurance claim adjustments.
| Question | Answer |
|---|---|
| Form Name | Clearwater Public Adjuster Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | adjusters retainer, public adjusters retainer form, public retainer agreement, public adjusters hereby |
All Lines Insurance Claims Public Adjusters
Public Adjuster’s Retainer Agreement
4314 SW 97 Avenue, Miami, Florida 33165
Ph 305 220 1420
THIS AGREEMENT is entered into this_______ day of___________________, 20____ by and between,
___________________________________________________________________the "INSURED" and
Lighthouse Public Adjusters, Inc.
The "INSURED" hereby retains Lighthouse Public Adjusters, Inc., a public adjusting firm, to represent
in the adjustment and negotiation of his/her insurance claim for the loss or damages caused by_______________
________________________________________________________________________ on or about____/____/______
At:_______________________________________________________________________________________________
Client Home Number____________________________Cell Phone Number __________________________________
Work Number_______________________________Email:_________________________________________________
Ins. Co. _________________________________________ Ph.______________________________________________
Policy # _________________________________Claim # _________________________ Paymentreceived $___________________
Mortgage Co._________________________________________ Loan Number_________________________________
Current on Mortgage Payments Yes____No___Months Behind__________Other Lien Holders_________________________________________
I n c o n s i d e r a t i o n f o r t h e a b o v e d e s c r i b e d s e r v i c e s , the "INSURED/CLAIMANT"
expressly agrees to pay Lighthouse Public Adjusters, Inc. the percentage of ______________ % from all proceeds of all
funds received in the settlement of his/her insurance claim regardless of whether the loss is settled or paid by the insurance company as a result of adjustment, mediation, appraisal, arbitration, lawsuit or otherwise on all coverages applicable under the described policy or any other applicable policy. If arising the case of additional costs associated with services necessary to settle this claim, including but not limited to: attorneys fees, engineers, appraisers or umpires, it will be addressed under a separate written agreement upon client’s approval.
The policyholder hereby authorizes and requests the insurance company that the name Lighthouse Public Adjusters, Inc. appears as a payee in addition to the other parties on all checks or drafts issued by the insurance company. In the event the insurance company fails to include Lighthouse Public Adjusters, Inc. on the check, the policyholder hereby grants Lighthouse Public Adjusters, Inc. a lien on recovered proceeds received by the policyholder to the extent of the fee due to Lighthouse Public Adjusters, Inc. pursuant to this agreement.
I, the INSURED/CLAIMANT authorize the mortgage company and/or bank to release a check for percentage of
______________ % to Lighthouse Public Adjusters, Inc., as the only payee since they have rendered their services to me and I wish
to settle their fee in advance should funds be disbursed partially and/or in payments. This agreement shall be binding upon the estate of the insured in the event of his /her death. In the event of litigation arising out of this agreement, venue for such action shall be in
If the insured decides not to proceed with the claim once we started our work, the insured will pay Lighthouse Public Adjusters for any expenses incurred up to that moment e.g.: estimator’s fee, engineering fee, or any other.
I, the insured hereby testifies that no other claim have been filed in reference with the same peril and that no other legal representation is involved with this claim other than: ______________________________________________________________
State claims filed for this property in the last five years, the date and amount of settlement :
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
If a problem arises during the claim process due to false information from the insured, resulting in a cancellation or denial, the insured will reimburse Lighthouse Public Adjusters for any expenses incurred.
The undersigned insured shall have the right to cancel by written document to Lighthouse Public Adjusters, Inc. this
agreement within ________________ days following the date this document is signed. The notification must be sent to the
office, certified mail and must be postmarked within the period stated above.
By signing below "The INSURED/CLAIMANT" acknowledges he/she understands and accepts the terms of this agreement and sates that all information provided herein is accurate.
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Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairscontains any false, incomplete, or misleading information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in s.775.082 s. 775.083 or s. 775.084 Florida Statues.