Step 1 of 4 25% Letter of RepresentationChoose Adjuster(Required)JEANNIE MARIE LUDWIN-BARGER - A109696SCOTT CRAIG BERNER - W558375MICHAEL BLICKER - W5300828COLE ALEXZANDER DALTON - W067964EILEEN MARY DALTON - W489995FRANCIS THOMAS DALTON JR. - P177776MARK JOSEPH HAZEL - W160440STEVEN BENJAMIN KITZMILLER - W489797TODD EDWARD MOREHEAD - W291189EMRA BENJAMIN PERRY - W204249CHRIS MATTHEW RIEHM - W586155ANTHONY JOSEPH RUGGIANO P169123AARON MICHAEL TUCK P057164ROBERT JOHN WERNER JR W001137CONSTANCE LEE GIRARD A097752CARLOS C PUENTE W720498JEFFREY T PARKER P197821MARILYN J DUMMITT P165201PETER ANTHONY GEMMI E150416KAYLA EILEEN HAYES W720913CRISTIN LAUREL TAYLOR W581004Matthew Kendall Reid W721795I/We(Required) (the “insured”), hereby retain COASTAL CLAIMS SERVICES, INC. to be my/our agent and representative to assist in the adjustment of my/our claim for loss and damages:Cause of loss(Required)FireWindHailVandalismWindstormWaterPipe BreakPipe LeakHurricaneOtherDate of Loss(Required) MM slash DD slash YYYY Loss Location(Required) Insurance Company(Required) Claim Number Policy Number(Required) • COASTAL CLAIMS SERVICES INC. will be recognized as a party of interest and must be contacted concerning settlement for this claim. • COASTAL CLAIMS SERVICES, INC. will be a payee on all payments made by the insurance company and all payments and correspondences will be sent to our National Headquarters at 2650 N. Dixie Freeway, New Smyrna Beach, FL 32168 , (386) 314-0074. • I/We, (the insured), authorize that a certified copy of the my/our owner’s insurance policy must be provided to COASTAL CLAIMS SERVICES, INC. • I/We, (the insured), also authorize COASTAL CLAIMS SERVICES, INC. to receive all documents that apply to my/our previous claims. • I/We have received a copy of this letter. InsuredSignature(Required)Print(Required) Date(Required) MM slash DD slash YYYY SignaturePrint Date MM slash DD slash YYYY HiddenCOASTAL CLAIMS SERVICES, INC. REPRESENTATIVE:HiddenSignature(Required)HiddenPrint(Required) HiddenDate(Required) MM slash DD slash YYYY “Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive an 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 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 Statutes.” Public Adjuster ContractChoose Adjuster(Required)JEANNIE MARIE LUDWIN-BARGER - A109696SCOTT CRAIG BERNER - W558375MICHAEL BLICKER - W5300828COLE ALEXZANDER DALTON - W067964EILEEN MARY DALTON - W489995FRANCIS THOMAS DALTON JR. - P177776MARK JOSEPH HAZEL - W160440STEVEN BENJAMIN KITZMILLER - W489797TODD EDWARD MOREHEAD - W291189EMRA BENJAMIN PERRY - W204249CHRIS MATTHEW RIEHM - W586155ANTHONY JOSEPH RUGGIANO P169123AARON MICHAEL TUCK P057164ROBERT JOHN WERNER JR W001137CONSTANCE LEE GIRARD A097752CARLOS C PUENTE W720498JEFFREY T PARKER P197821MARILYN J DUMMITT P165201PETER ANTHONY GEMMI E150416KAYLA EILEEN HAYES W720913CRISTIN LAUREL TAYLOR W581004Policy #(Required) Claim # Insurance Company(Required) Insured Name(Required) Street Address of Loss Location(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured’s Phone #(Required)(Required) Emergency Non-Emergency Supplemental Date of Loss MM slash DD slash YYYY *Brief Description of Loss:(Required)I/We(Required) (hereinafter referred to as the insured), hereby retain COASTAL CLAIMS SERVICES, INC. to be my/our agent and representative to assist in the adjustment of my/our claim for loss and damages.I/We agree to pay(Required) non-emergency / supplemental claim amount emergency amount of this insurance loss I/We agree that COASTAL CLAIMS SERVICES, INC., shall be entitled to 20%, 10%, or other agreed upon percentage as indicated in the previous paragraph, regardless of how the claim is settled, compromised, resolved, covered, or paid by the insurance carrier/company. Further, the 20%, 10%, or other agreed upon percentage as indicated in the previous paragraph, is owed regardless of the method of resolving the claim including but not limited to: a) adjustment of the claim; b) mediation; c) appraisal; d) arbitration; e) lawsuit; f) or otherwise, on all coverage applicable under the subject policy of this claim and any other applicable policy including but not limited to claims, equitable claims, legal claims, claims for bad faith and/or extra contractual claims.I/We agree to pay ONLY if there is a payment of insurance proceeds, award or settlement. If this is a supplemental claim, over and above COASTAL CLAIMS SERVICES, INC. reserves the right to release the insured at any time for good and cause and with reasonable notice. I/We understand and agree that if it becomes necessary to retain an attorney, I/we authorize and agree to a Letter of Protection for COASTAL CLAIMS SERVICES, INC. I/We shall direct our attorney to prepare a Letter of Protection, which is a legally binding document signed by all parties and the attorney, that directs our attorney to pay the fees and costs due under this Agreement from any recovery by us for our loss. If the insured hires any additional services, such as: engineers, experts, appraisers, umpires, lawyers, etc., COASTAL CLAIMS SERVICES, INC. will not be responsible for their fees. It is expressly agreed and understood that any and all costs incurred will be the sole and absolute responsibility of the insured. You, the insured 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 COASTAL CLAIMS SERVICES, INC., submitted in writing and sent by certified mail, return receipt requested, or other form of mailing that provides proof thereof at the address provided in the contract.I/We further understand and agree to the following terms: Mortgage Company: It is hereby acknowledged and understood that any and all mortgagees with legal or equitable interest in the property which is subject to the insurance claim may be named as additional payees for all real property damage. It is further understood that COASTAL CLAIMS SERVICES, INC. is expressly authorized to discuss specific loan account information relating to the insurance claim on the subject property. The insured expressly authorizes and hereby directs any mortgagee incumbering the subject property to include COASTAL CLAIMS SERVICES, INC. as an additional payee on all checks issued and/or distributed by any insurance carrier representing insurance proceeds issued as a result of the damages incurred to the subject property. Public Adjusting Fee: Payment in full to COASTAL CLAIMS SERVICES, INC. shall be immediately due and payable by the insured at the time that the insurance proceeds are paid or repair rendered by the insurance company and in the event of any dispute or litigation regarding non-payment of public adjusting fees the prevailing party shall be entitled to recover reasonable attorney’s fees and any and all costs whether foreseeable or not. The insured further acknowledges that COASTAL CLAIMS SERVICES, INC. is entitled to interest at the rate of 18% per year in the event of a default under the terms of this payment paragraph. The insured hereby specifically and expressly authorizes COASTAL CLAIMS SERVICES, INC. to deposit payments received by the insurance carrier into COASTAL CLAIMS SERVICES, INC. checking account to ensure that the check clears from said insurance company. In the event that the check does not clear the insured hereby authorizes COASTAL CLAIMS SERVICES, INC. to contact the insurance carrier to request reissuance of the check. The insured further acknowledges that COASTAL CLAIMS SERVICES, INC. is not a law firm and has not represented itself as such to the insured and in the event of an insurance carrier issuing a worthless check prompt consultation with a duly licensed attorney in Florida is highly recommended. Assignment of Insurance Proceeds: The insured hereby expressly and unequivocally assigns to COASTAL CLAIMS SERVICES, INC. and COASTAL CLAIMS SERVICES, INC. shall have a lien on the portion of the insurance proceeds sufficient to pay COASTAL CLAIMS SERVICES, INC. the full amount due and owing under the terms of this agreement. Settlement Authority: The insured agrees that no settlement of any claim will occur unless COASTAL CLAIMS SERVICES, INC., is in agreement of the settlement amount. The insured agrees that if the need arises, COASTAL CLAIMS SERVICES, INC., is authorized to invoke mediation on your behalf. Venue, Governing Law, Law, Severability: This agreement shall be governed and be construed in accordance with the laws of the state of Florida. In the event of any lawsuit, legal action proceeding whether administrative or otherwise venue for the proceeding shall be exclusively Volusia County, Florida. This agreement shall be interpreted as if it was drafted by both parties. The insured agrees that no contractual rules or doctrines of interpretation of contract law shall apply against COASTAL CLAIMS SERVICES, INC. in any judicial or administrative proceeding or interpretation of this agreement. In the event that any portion of this agreement is found to be invalid, illegal or unenforceable, the remainder of this agreement shall remain in full force and effect. No action in equity will lie unless the insured has fully and strictly complied with the terms of this agreement. No modification to this agreement shall be valid unless it is executed in writing and signed by all parties. The insured hereby acknowledges the sufficiency of the consideration given by COASTAL CLAIMS SERVICES, INC. in the performance of its duties under this contract. Authorization to Use/Publish Media: The insured hereby grants COASTAL CLAIMS SERVICES, INC. an unrestricted and absolute right to use, any image, video or audio recording of any of the insured or any of the insured’s property for any purpose whatsoever. The insured further authorizes COASTAL CLAIMS SERVICES, INC. to combine any image, video or audio recording with any text, graphics or other creative element for the purpose of creating an advertisement. The insureds acknowledge and hereby authorize the manipulation, alteration, redaction or modification of any image, video or audio recording of themselves or their property. Future Cooperation: Insured agrees to cooperate with COASTAL CLAIMS SERVICES, INC. in the performance of it duties under this contract. Additionally, the insured agrees to execute any document reasonably necessary to accomplish this public adjusting services contract or to secure payment from any source. Fraud Warning: “Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive an 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 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 Statutes.” I/We have received a copy of this contract.Signature(Required)Print(Required) Date(Required) MM slash DD slash YYYY SignaturePrint Date MM slash DD slash YYYY HiddenCOASTAL CLAIMS SERVICES, INC. REPRESENTATIVE:HiddenSignature(Required)HiddenPrint(Required) HiddenDate(Required) MM slash DD slash YYYY Claims Handling Process• Step 1: Initial Contact- Whether you have contacted us via phone 386-314-0074, email: info@coastalclaims.net, or through our website www.coastalclaims.net, an adjuster from COASTAL CLAIMS SERVICES, INC. will respond to you as quickly as possible. We will review your information, explain the claims process in depth, answer any questions you may have and schedule an initial inspection of your damage. • Step 2: Appointment of Coastal Claims Services, Inc. to represent you- For COASTAL CLAIMS SERVICES, INC. to represent you, we must have authorization allowing us to have contact with your insurance company. To do that, we will need a signed authorization form so that we can notify the insurance company to discuss your claim, negotiate scope of loss and any insurance settlements. This is our Letter of Representation. Also, at this time, we will discuss our fees with you based on your needs and coverages. Our fee is 20% of the claim total, unless the damage occurred during a declared state of emergency, in which it becomes 10% of the claim made during the first year after the declaration of the emergency. COASTAL CLAIMS SERVICES, INC. wants to make sure that any fees and related expenses are understood up front so there are no surprises. After the fees are explained and agreed upon, we will have all involved parties sign our Public Adjuster Contract. • Step 3: Investigation- After the COASTAL CLAIMS SERVICES, INC. adjuster opens the claim and sends our Letter of Representation to the insurance company, we will coordinate with the insurance company’s adjuster (Field Adjuster). This means that we may need to schedule another site visit with the Field Adjuster and/or coordinate our findings with the Field Adjuster via phone call or email. At this time, the COASTAL CLAIMS SERVICES, INC. adjuster will submit an estimate along with any photos or other pertinent information needed for your claim. The Field Adjuster from your insurance company will also submit his/her findings as well. This process may take up to three weeks. • Step 4: Negotiations and Settlement: Once your insurance company reviews and compares both estimates (the estimate from COASTAL CLAIMS SERVICES, INC. and the estimate from their Field Adjuster), the insurance company will likely contact our office and propose a settlement. Since this process can take a few weeks after submission of the estimates, we initiate claims status follow-up on your behalf to expedite the processing of your claim. We will never settle a claim without prior approval from you. Once a settlement is approved, the insurance company will send a check to either your mailing address or to the COASTAL CLAIMS SERVICES, INC. office. The check is usually made payable to all parties involved with the claim. For example: the homeowner, COASTAL CLAIMS SERVICES, INC., the mortgage company, and sometimes the contractor, if applicable. Before we can release the check to you, we will provide you with an invoice from COASTAL CLAIMS SERVICES, INC. and we will need to receive the agreed upon payment from you. At that time, COASTAL CLAIMS SERVICES, INC. will be able to make the proper arrangements to have the check endorsed. •*LASTLY, when our investigation is complete, and we submit the estimate to your insurance company, the insurance company can take up to 90 days, or three months, to notify you of denial or acceptance of your claim. Because of this lengthy process, there might be a period of inactivity during your claim. Our adjusters are handling many claims at a time and may not be in contact with you during this period. We will only contact you if we require additional information or documents. As soon as we have an update on the status of your claim, we will be in touch with you immediately. If you would like to request an update on your claim during this time, we will be more than happy to provide you with the most up to date information by contacting our office directly.* I/We understand and agree upon the Claims Handling Process and have received a copy of this form:Signature(Required)Print(Required) Date MM slash DD slash YYYY SignaturePrint Date MM slash DD slash YYYY CLIENT INFORMATIONHomeowner’s InformationName(s) of Insured:(Required) First Last Property Address of Loss Location(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Main Phone Number(Required)Alternate Phone NumberEmail(Required) Insurance InformationName of Insurance Company(Required) Policy Number(Required) Claim Number Date of Loss(Required) MM slash DD slash YYYY Cause of Loss(Required) Interior Damages(Required) Yes No Exterior Damages(Required) Yes No Brief Description of the Damages(Required)Mortgage InformationMortgage associated with the property Yes No Mortgage Company Name Contractor Information How were you referred to Coastal Claims Services, Inc.? (Please Explain):(Required)
