Full Name(s): Email:
Address: City: County: State: Zip:
Phone: Fax: Cell:
Full Name: XXX License No.XXXX
Phone:  Fax:  Email:
Public Adjuster Firm Name:EXECUTIVE CLAIM SOLUTIONS LLC Claim Type:Emergency

Loss Address: City: County: State: Zip:
Date of Loss: Did Loss Occur During a State of Emergency? Yes No  
Description of Loss:
Company Name: Policy/Claim No.
Company Name: Loan No.
Borrower Name(s), if different from Policyholder:

The above-referenced Policyholder(s) (collectively referred to as “POLICYHOLDER”) and the PUBLIC ADJUSTER (collectively referred to as “PARTIES”) enter into this Public Adjuster Services Agreement (this “Agreement”) for the following described services (the “Services”) relating to the above-referenced loss (the “LOSS”), pursuant to the following terms and conditions, which are incorporated herein for all purposes:

  1. SERVICES: PUBLIC ADJUSTER will act as a public insurance adjuster on behalf of POLICYHOLDER for the services provided and fees will be paid upon the preparation and/or presentment of the claim for loss, damage, and recovery for the LOSS under any insurance policies including those listed above relating to the following insurance coverage provided in the policy(ies). This does not include assisting in any appraisal/mediation/arbitration or legal proceedings whether contractual or extra-contractual. 
  2. NOTICE OF PUBLIC INSURANCE ADJUSTER SERVICES AND OF ASSIGNMENT: POLICYHOLDER further agrees and confirms that a portion of the recovery from any insurance company has been assigned by POLICYHOLDER to ADJUSTER. Accordingly, POLICYHOLDER has instructed and hereby instructs all insurance companies and authorizes PUBLIC

ADJUSTER to direct all insurance companies to make payment in the form of checks and/or drafts prepared by insurance companies for fees relating to this Agreement to PUBLIC ADJUSTER separate from POLICYHOLDER, based on the appropriate fees for services as stipulated in clause 4 of this Agreement with the balance made payable to the POLICYHOLDER. POLICYHOLDER also has instructed and hereby instructs all insurance companies and authorizes PUBLIC ADJUSTER to direct that all communications, correspondence, checks, and/or drafts be addressed and sent to PUBLIC ADJUSTER with a copy of all communications, correspondence, drafts, and checks sent to the POLICYHOLDER. All risk and/or damage inspections are to be coordinated with and through PUBLIC ADJUSTER.

POLICYHOLDER has instructed and hereby instructs all insurance companies and authorizes PUBLIC ADJUSTER to direct all insurance companies to provide PUBLIC ADJUSTER/POLICYHOLDER with the following within ten (10) days from notice for each policy of insurance (including, but not limited to, coverage forms, amendatory endorsements, and/or exclusions) that may in any way provide coverage for the LOSS: (1) a certified copy of each of the policy(ies), including declaration page and any applicable exclusions, endorsements, etc.; (2) the type and limits of the coverages afforded by each policy; and (3) a statement of any policy or coverage defense that insurer reasonably believes is available to such insurer at the time of filing such statement for each policy. It is requested that the insurance company assure that all policy provisions are complied with in processing POLICYHOLDER’s claim. Please note that it is POLICYHOLDER’s intention to make a claim for loss and/or damage relating to any replacement cost provisions of the policy of insurance. Further, the insurance company must immediately send to PUBLIC ADJUSTER and POLICYHOLDER any additional or supplemental documentation or information that may be discovered in the future relating to this request.

3. CANCELLATION OF AGREEMENT: You, the insured (POLICYHOLDER) may cancel this contract for any reason without penalty or obligation to you within ten (10) days after the date of this contract by providing notice to the PUBLIC ADJUSTER, submitted in writing and sent by certified mail, return receipt requested, or another form of mailing that provides proof of mailing thereof to the PUBLIC ADJUSTER at the address specified in this contract. If during the pendency of this Agreement PUBLIC ADJUSTER determines within its sole discretion that POLICYHOLDER can no longer be represented for any reason, PUBLIC ADJUSTER may withdraw from further representation.

  1. FEES FOR SERVICES: POLICYHOLDER understands and agrees that PUBLIC ADJUSTER shall solely and exclusively recover its fees based on the amount recovered from an insurance company regardless of where or to whom those funds are delivered, and no other source of funds, for the LOSS including, but not limited to, compromise, confession of liability, appraisal awards, judgments, awards and/or settlements of damages, costs, interest, fees, and/or payments of POLICYHOLDER’s liens, bills, or claims. PUBLIC ADJUSTER’s fee shall be immediately due and payable upon the insurance company making any payment separately from payment to POLICYHOLDER. The fee calculation shall be computed after costs are subtracted from the total amount recovered. The amount of the PUBLIC ADJUSTER’s fees shall be computed as follows:

  percent of the amount of claim payments by any insurance company for the LOSS or

  percent of the amount of any new claim payments in excess of $ considered as sums due/paid for damages determined by any insurance company for the LOSS.

Ten percent of the amount of claim payments by any insurance company for the LOSS, if the claim is based on events that are the subject of a declaration of a state of emergency by the Governor and the claims are made during the period of 1 year after the declaration of emergency. POLICYHOLDER and PUBLIC ADJUSTER understand and agree that the percentages provided in this Agreement comply with Florida law in effect as of the date of this Agreement. If the provision of any state or federal rule or statute requires payment of fees in a lesser amount than those set forth above, then POLICYHOLDER and PUBLIC ADJUSTER understand that POLICYHOLDER will be charged only the lesser amount provided for in said rule or statute.


POLICYHOLDER understands and agrees that in the event the insurance company elects to repair the insured property rather than pay the amount of covered loss, PUBLIC ADJUSTER shall still be entitled to recover its fees from the insurance company, in the same percentage as set forth above.

The PUBLIC ADJUSTER shall not be compensated by contractors or attorneys.

  1. EXPENSES/COSTS: PUBLIC ADJUSTER will pay costs it deems necessary to substantiate this claim. POLICYHOLDER understands and agrees that if POLICYHOLDER authorizes in writing PUBLIC ADJUSTER to pay on POLICYHOLDER’s behalf such costs and expenses the PUBLIC

ADJUSTER deems necessary from time to time to investigate, prepare a claim, settle a claim, and/or take other action the ADJUSTER deems necessary to pursue POLICYHOLDER’s claim, POLICYHOLDER understands such costs and expenses advanced by PUBLIC ADJUSTER on POLICYHOLDER’s behalf are payable to PUBLIC ADJUSTER and shall be deducted from any recovery after fees for services are computed and paid to PUBLIC ADJUSTER. If there is any recovery, whether during the time of service by PUBLIC ADJUSTER, service by another public insurance adjuster, representation by an attorney, or without services provided by an adjuster or attorney, PUBLIC ADJUSTER will be entitled to recovery of all reasonable fees and expenses/costs expended in the processing of POLICYHOLDER’s claim. POLICYHOLDER understands that if POLICYHOLDER elects to terminate PUBLIC ADJUSTER, POLICYHOLDER shall immediately pay PUBLIC ADJUSTER all costs and expenses of PUBLIC ADJUSTER and shall remain responsible for all fees for services rendered pursuant to this Agreement and, in addition to any other available remedy, PUBLIC ADJUSTER shall have a lien and a claim for quantum meruit on any recovery from this claim.

  1. ESTIMATES. The PUBLIC ADJUSTER will send detailed estimates, which include itemized repair costs, 60 days after signing this agreement and the PUBLIC ADJUSTER will retain those records for five years and be make them available upon request.
  2. ENDORSING CHECKS.    If POLICYHOLDER, for any reason, receives a claim proceeds check from an insurance company (a “Proceeds Check”), POLICYHOLDER agrees to promptly, but in any event within fourteen (14) business days of receipt of the Proceeds Check, endorse and deliver the Proceeds Check to the PUBLIC ADJUSTER. If POLICYHOLDER fails to comply with the foregoing, POLICYHOLDER shall pay the lesser of 18% interest per annum or the maximum interest allowable by law on the amount of the PUBLIC ADJUSTER’s fee due from the Proceeds Check and that PUBLIC ADJUSTER shall be entitled to, along with any and all other remedies to which PUBLIC ADJUSTER may be entitled, the immediate issuance of a writ of replevin requiring POLICYHOLDER to immediately deliver the Proceeds Check to the PUBLIC ADJUSTER, and waives all defenses to same except for compliance with the foregoing.
  3. LETTER OF PROTECTION: POLICYHOLDER understands and agrees that if it becomes necessary to retain an attorney, POLICYHOLDER authorizes and agrees to a Letter of Protection for the PUBLIC ADJUSTER. POLICYHOLDER shall direct POLICYHOLDER’S attorney to prepare a Letter of Protection, which is a legally binding document signed by the PARTIES and the attorney, that directs POLICYHOLDER’s attorney to pay the fees and costs due under this Agreement from any recovery by POLICYHOLDER for the LOSS. POLICYHOLDER further agrees that, notwithstanding any objection to same, PUBLIC ADJUSTER is authorized to pay any and all contractors (“Contractor”) with whom POLICYHOLDER contracts for repairs or other work related to or funded by the proceeds from the claim, and if POLICYHOLDER objects to same, POLICYHOLDER shall indemnify PUBLIC ADJUSTER (using, at PUBLIC ADJUSTER’s option, the claim proceeds) for any and all claims, demands, and liabilities incurred by PUBLIC ADJUSTER related to or caused by same.

If the POLICYHOLDER executes both a Letter of Protection (or substantially similar instrument) and an Assignment of Benefits (or substantially similar instrument) relative to the same claim, then the POLICYHOLDER and assignee agree that the PUBLIC ADJUSTER shall automatically represent whichever of the POLICYHOLDER or assignee owns the claim, as may be the case from time to time. Both the POLICYHOLDER and assignee agree to promptly notify the PUBLIC ADJUSTER if the owner of the claim changes during the term of this Agreement, regardless of the mechanism effectuating such change in ownership. The POLICYHOLDER further agrees that, regardless of anything herein or in any other contract, instrument, or agreement, assignee shall be entitled, in assignee’s sole and absolute discretion, to determine whether to proceed under the Assignment of Benefits or under the Letter of Protection, from time to time, without notice to the POLICYHOLDER except as may be required by applicable law, and further agrees to execute and provide any documents the assignee and PUBLIC ADJUSTER may request in relation to the claim, the Assignment of Benefits, and the Letter of Protection.

  1. CONFLICT WAIVER: POLICYHOLDER acknowledges, agrees, and to the maximum extent allowable under applicable law, waives, indemnifies, and holds harmless PUBLIC ADJUSTER in relation to any actual or potential conflict of interest, as well as any claim against PUBLIC ADJUSTER related to same, in the event of a dispute or conflict of interest between POLICYHOLDER, PUBLIC ADJUSTER, and/or Contractor, including without limitation a dispute or conflict of interest related to the amount of any proceeds recovered at POLICYHOLDER’s direction in relation to the claim relative to the scope and price of the services Contractor agreed to provide. For purposes of example and not limitation, if POLICYHOLDER directs PUBLIC ADJUSTER to accept an amount of insurance proceeds which is less than the amount Contractor believes is reasonable, appropriate, or necessary for Contractor to perform the work which Contractor agreed to perform in exchange for such proceeds, then a conflict or dispute may arise between Contractor, POLICYHOLDER, and/or PUBLIC ADJUSTER. In that case, POLICYHOLDER agrees that PUBLIC ADJUSTER has advised POLICYHOLDER of this potential risk, and knowingly and intelligently waives any and all claims a dispute conflicts of interest against PUBLIC ADJUSTER related to same.
  2. PROVISIONS CONCERNING SERVICES: POLICYHOLDER and PUBLIC ADJUSTER understand and agree that neither party shall settle any claims arising out of the LOSS without first obtaining the consent of the other. POLICYHOLDER’s deposit or negotiation of a claim payment is evidence of POLICYHOLDER’s consent to settlement. POLICYHOLDER hereby authorizes and directs any and all mortgagees of POLICYHOLDER to include PUBLIC ADJUSTER as a payee on any and all disbursements related to the Claim. POLICYHOLDER agrees to cooperate with PUBLIC ADJUSTER, to be available for preparation of the claim, conferences, appraisal, and/or mediation, and to keep PUBLIC ADJUSTER fully informed of all matters relating to this LOSS. POLICYHOLDER acknowledges that PUBLIC ADJUSTER has made no guarantees regarding the disposition or results of any stage of the claims process, and all expressions made on behalf of PUBLIC ADJUSTER are the opinion of PUBLIC ADJUSTER based on information known at that time. This Agreement provides the complete and only agreement between POLICYHOLDER and PUBLIC ADJUSTER with respect to the above-referenced LOSS, and supersedes all prior written and oral offers, proposals, and agreements. No modification, waiver, amendment, discharge, or change of this Agreement shall be valid unless the same is in writing. In the event, a dispute between the parties arises and a suit is filed, the venue of such suit shall be in the County in Florida where PUBLIC ADJUSTER’s above address is located. The substantive law of the State of Florida shall govern this Agreement. Any failure by either party to comply with any provision of this Agreement may be waived, but only if such waiver is in writing and signed by the other party. Any failure to insist upon or enforce compliance with any provision of this Agreement shall not operate as a waiver of, or estoppel with respect to, any other or subsequent failure. Any notice required or permitted to be given under this Agreement shall be sufficient if in writing, and if hand-delivered, sent by Federal Express or similar overnight carrier, or sent by registered or certified United States Mail, return receipt requested, to the addresses set forth in this Agreement, or to such other address as a party may designate in accordance with this provision, unless specified otherwise for a particular provision in this Agreement. This Agreement shall not be construed more strictly against PUBLIC ADJUSTER simply because it was the party responsible for preparing this Agreement. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original, but all of which together shall constitute one in the same instrument. A copy of this Agreement transmitted by telefacsimile, email, and/or other electronic forms shall be deemed an original. 
  3. NO LEGAL SERVICES PROVIDED: This Agreement is not for legal services and PUBLIC ADJUSTER cannot provide legal services. Any legal services must be provided by an attorney. POLICYHOLDER understands and agrees that POLICYHOLDER will need to enter into a separate written agreement with an attorney of his/her choice and make separate payment for such services provided for representation. PUBLIC ADJUSTER encourages POLICYHOLDER to seek appropriate legal services if necessary. Upon request, PUBLIC ADJUSTER may provide names of attorneys that other policyholders have retained and indicated provided satisfactory services. If none of the attorneys named are satisfactory to POLICYHOLDER, PUBLIC ADJUSTER may be able to provide additional names. POLICYHOLDER should always seek legal representation from the attorney of his/her choice.
  4. POLICYHOLDER authorizes the Insurance Company and/or Mortgage Company (both herein referenced on the table included on page 1 of the agreement) to provide the following information regarding the claim referenced within this agreement and associated loan/mortgage to PUBLIC ADJUSTER. POLICYHOLDER agrees that this authorization is valid until the closure of the insurance claim:

Access to discuss all information regarding my insurance claim loss; Access to discuss all documentation pertaining to my insurance claim loss;

Access to all information regarding payments pertaining to my insurance claim; and Relationship of Authorized Party to insured.


  1. STATEMENT OF CLAIM: POLICYHOLDER understands and acknowledges that 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 repairs contains 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. 775.803, or s. 775.084, Florida Statute s. POLICYHOLDER shall confirm the accuracy and completeness of any and all information and documentation provided to PUBLIC ADJUSTER and any and all forms or other documents signed and/or provided to the insurance company for purposes of adjusting through the preparation and submission of a claim for loss, damage, and recovery under any insurance policy.

This Agreement may be amended only by the written consent of the Parties hereto. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision. This Agreement constitutes the entire agreement between the Parties. It supersedes all prior oral or written agreements or understandings between the Parties concerning the subject matter of this Agreement. The parties will exercise utmost good faith in this Agreement. Except where otherwise provided, failure by either Party to enforce any of these terms or conditions shall not be a waiver of their right to enforce them. No waiver by that Party of any breach of, or of compliance with, any condition or provision of this Agreement by the other Party shall be considered a waiver of any other condition or provision or of the same condition or provision at another time. This Agreement may be executed in any number of counterparts, each of which shall be an original and all of which constitute the same instrument. The Article and Section headings in this Agreement are for convenience, and they form in no part of this Agreement and shall not affect its interpretation. Whenever used herein, the singular number shall include the plural, and the plural number shall include the singular. Any references herein to the masculine gender or the masculine form of any noun, adjective, or possessive shall be construed to include the feminine or neuter gender and form, and vice versa. This Agreement shall be governed in all respects by the laws of Florida and its Courts without regard to its conflict of law provisions.

  1. ATTACHMENTS: There         are        are not (check one) attachments to this Agreement.
  1. POLICYHOLDER is signing this Agreement on POLICYHOLDER’s own behalf and in any representative capacity appropriate to the circumstances. By executing below, POLICYHOLDER specifically agrees to be bound by this Agreement, including the provisions set out above and on the back of this Agreement, which are incorporated herein for all purposes. POLICYHOLDER hereby acknowledges receipt of a copy of this Agreement and that the Adjuster that solicited this Agreement has signed below.
Date: By: Signature of POLICYHOLDER
    Print Name of POLICYHOLDER



  Signature of POLICYHOLDER
    Print Name of POLICYHOLDER



  Signature of PUBLIC ADJUSTER
    ZZZZ                                    Print Name of PUBLIC ADJUSTER



  Signature of ASSIGNEE, if applicable
Print Name of ASSIGNEE Firm   Print Name of ASSIGNEE Representative, if applicable

* An unaltered copy of this executed contract will be sent to the insurer within 30 days after execution.

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