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Letter of Representation

(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:
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• 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.

Insured

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COASTAL CLAIMS SERVICES, INC. REPRESENTATIVE:

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“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.”