Florida Contract Form | Coastal Claims Services

Letter of Representation, Contract and Claims Handling Process Form

Choose Adjuster(Required)

Names of Insured(s)(Required)

Insured’s Phone #(Required)

Alternate Phone Number

Email(Required)

Insurance Company(Required)

Claim Number

Policy Number(Required)

Street Address of Loss Location(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Cause of loss(Required)

Date of Loss

September 28, 2022

September 29, 2022

Interior Damages(Required)

Yes

Exterior Damages(Required)

Yes

*Brief Description of Loss:(Required)

Type of Claim

Emergency

I/We agree to pay

non-emergency / supplemental claim amount (20%)

of the amount of this insurance loss

Type of Claim1

Non-Emergent

I/We agree to pay 1

emergency amount of this insurance loss (10%)

of the amount of this insurance loss

Type of Claim2

Supplemental

% Amount from Above

20%

10%

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(Required)

Mortgage Associated with the Property(Required)

Yes

Mortgage Company Name(Required)

Contractor Information

How were you referred to Coastal Claims Services, Inc.? (Please Explain):(Required)

Insured Name(Required)

Date(Required)

Is the insured filing for an Additional Living Expense Claim?(Required)

Yes

OPTIONAL: Additional Living Expense Claim

I agree to retain and compensate Coastal Claims Services, Inc. for adjusting my additional living expenses and securing payment from my insurer for amounts attributable to additional living expenses payable under the policy issued on my Home, Mobile home, Condominium unit (Check ONE BELOW). I agree to pay Coastal Claims Services a fee of 10% of total funds and/or benefits received attributable to the Additional Living Expense portion of my residential claim, which fee shall not cause the total fee charged by Coastal Claims Services to exceed statutory limits.

Additional Living Expense Claim

Home

Untitled

Mobile Home

Untitled

Condominium Unit

Insured Name for Additiona Living Expense Addendum(Required)