Clearwater Public Adjuster Form – Fill Out and Use This PDF

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 Miami-Dade County, Florida and the prevailing party shall be entitled to recover its court costs and reasonable attorney fees, including those of any appealing proceedings.

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.

Client/s (Name Print)

Client/s (Signature)

Date

Client/s (Name Print)		Client/s (Signature)			Date
Lighthouse’s Adjuster (Name)		Lighthouse’s Adjuster (Signature)		Date	Public Adjuster License #

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.