Full Name*
First
Last
Phone*
Full Name of Second Person on Policy (if applicable)
First
Last
Phone of Second Person on Policy (if applicable)
Email*
Physical Address of the property to be inspected*
Are you already speaking with one of our Public Adjusters? Select your Public Adjuster Stephen R. Lippy Sacha Ducrocq Julian Leinhardt David Flaks Brennan Rimer Richard Cress Chris Gay
House, Condo or Business?* House Condo Business
Homeowners Insurance Company*
Business Insurance Company*
Policy Number*
Did you already call the claim in?* If so, what is your claim number?
In DOLLAR AMOUNT, what is the amount of your deductible? ****If you cannot find this, please make sure to attach a copy of your coverage in the pdf field below.*****
Claim Type* ⚠️Please fill out one form for Hurricane (wind) damage AND one form if you have Hurricane Ian flood damage. If you have both wind and flood damage, please fill out both forms completely. Thank you!⚠️
Please select Hurricane Ian Hurricane Ian(Flood) Tropical Storm Nicole Water Roof Leak Wind Hail Lightning Fire A/C Leak Pipe Break Sewer Backup Business Interruption Business Interruption Covid 19 Other
What Year Was Your Roof Installed?*
Date of Loss*
MM slash DD slash YYYY
Date of Loss*
MM slash DD slash YYYY
Cause of Loss Please provide as much detail as necessary to explain the cause of loss or damage to your home.
Please describe your damage*
Please describe your damage*
Please describe your damage*
Notes
Upload Documents Please upload your homeowner's insurance declaration page or email it to info@flbestpa.com
Upload extra documents Please upload photos of damage that you may have available, any correspondance from the insurance company as well as any other documents you deem important for us to have to help you.
The undersigned (the Insured) hereby retains the above Public Insurance Adjuster, Florida’s Very Best Public Adjusters, Inc. (the PA) to be the Insured's representative in the adjustment of the above-referenced loss. The Insured understands and agrees that PA has retained Bulldog Adjusters, Inc. to provide administration services for all claims adjusted by PA including the Insured’s claim that is the subject of this Agreement. The Insured therefore understands and agrees that Bulldog Adjusters, Inc. will be entitled to receive a portion of the fees set forth below.
The Insured hereby agrees to pay to PA and Bulldog Adjusters, Inc., jointly, an amount equal to 20% of the gross amount of the collected loss or damage recovered regardless of whether the loss is settled or paid by the insurance company or by reason of the above referenced policy as a result of adjustment, mediation, appraisal, arbitration, lawsuit or otherwise, on all coverage applicable under the referenced policy or any other applicable policy, including, without limitation, claims for bad faith and extra-contractual damages or loss (hereafter referred to as the "PA fee"). If no recovery is made, the Insured will not be indebted to the Public Adjuster (PA) and Bulldog Adjusters Inc. for any sum of fees.
The Insured hereby authorizes the PA to contact the above-named insurance company to direct them to include the name of Bulldog Adjusters, Inc. as a payee on any and all insurance proceeds checks issued by reason of the above referenced loss. This provision shall remain in full force and effect unless revoked by mutual written agreement of the insured and PA.
Payment to the PA shall be due and payable in full at the time that insurance proceeds are paid or issued by the insurance company. In consideration for the PA's professional services, the Insured by this agreement hereby irrevocably assigns to the PA, and the PA shall have a lien on, the portion of the insurance proceeds paid or payable sufficient to pay the amount due the PA under the agreement. In the event legal proceedings are brought by the PA to enforce this agreement, the prevailing party shall be entitled to recover its court costs and reasonable attorney’s fee, including those of any appellate proceedings. Venue for all legal proceedings to be held in the courts of Broward County, Florida.
You, the insured, may cancel this contract for any reason without penalty or obligation to you within 10 days after the date of this contract by providing notice to Florida’s Very Best Public Adjusters, LLC. submitted in writing and sent by certified mail, return receipt requested or other form of mailing that provides proof thereof, at the address specified herein: 499 NW 70th Avenue, Suite 114, Plantation, Florida 33317.
The Insured hereby authorizes the PA to hire the professional services of appraisers, umpires, estimators, engineers, and any other experts as may be deemed necessary by the PA. Any costs associated with said claims recovery will be reimbursed to the PA. The Insured must consent to the cost prior to the PA hiring said professional(s).
The Insured acknowledges that the PA has made no guarantees regarding the disposition or results of any stage of the claims process and all expressions made on behalf of the PA are the opinion of the PA based on information known at that time.
PA shall not be liable for property conditions or information pertinent to the claim not presented or requested by the Insured or the Insured’s contractor that are not included in the PA’s scope of professional services. PA shall undertake only the professional services required for the issues presented or requested by the Insured or Insured’s contractor, as determined by PA in its discretion.
The Insured represents that all information given to the PA is true and accurate. The Insured understands that pursuant to §.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 §.775.082, §.775.803, or §.775.084, Florida statutes. The Insured understands that the PA relies on the information provided by the Insured.
The undersigned (the Insured) hereby retains the above Public Insurance Adjuster, Florida’s Very Best Public Adjusters, Inc. (the PA) to be the Insured's representative in the adjustment of the above-referenced loss. The Insured understands and agrees that PA has retained Bulldog Adjusters, Inc. to provide administration services for all claims adjusted by PA including the Insured’s claim that is the subject of this Agreement. The Insured therefore understands and agrees that Bulldog Adjusters, Inc. will be entitled to receive a portion of the fees set forth below.
The Insured hereby agrees to pay to PA and Bulldog Adjusters, Inc., jointly, an amount equal to 10% of the gross amount of the collected loss or damage recovered regardless of whether the loss is settled or paid by the insurance company or by reason of the above referenced policy as a result of adjustment, mediation, appraisal, arbitration, lawsuit or otherwise, on all coverage applicable under the referenced policy or any other applicable policy, including, without limitation, claims for bad faith and extra-contractual damages or loss (hereafter referred to as the "PA fee"). If no recovery is made, the Insured will not be indebted to the Public Adjuster (PA) and Bulldog Adjusters Inc. for any sum of fees.
The Insured hereby authorizes the PA to contact the above-named insurance company to direct them to include the name of Bulldog Adjusters, Inc. as a payee on any and all insurance proceeds checks issued by reason of the above referenced loss. This provision shall remain in full force and effect unless revoked by mutual written agreement of the insured and PA.
Payment to the PA shall be due and payable in full at the time that insurance proceeds are paid or issued by the insurance company. In consideration for the PA's professional services, the Insured by this agreement hereby irrevocably assigns to the PA, and the PA shall have a lien on, the portion of the insurance proceeds paid or payable sufficient to pay the amount due the PA under the agreement. In the event legal proceedings are brought by the PA to enforce this agreement, the prevailing party shall be entitled to recover its court costs and reasonable attorney’s fee, including those of any appellate proceedings. Venue for all legal proceedings to be held in the courts of Broward County, Florida.
You, the insured, may cancel this contract for any reason without penalty or obligation to you within 10 days after the date of this contract by providing notice to Florida’s Very Best Public Adjusters, LLC. submitted in writing and sent by certified mail, return receipt requested or other form of mailing that provides proof thereof, at the address specified herein: 499 NW 70th Avenue, Suite 114, Plantation, Florida 33317.
The Insured hereby authorizes the PA to hire the professional services of appraisers, umpires, estimators, engineers, and any other experts as may be deemed necessary by the PA. Any costs associated with said claims recovery will be reimbursed to the PA. The Insured must consent to the cost prior to the PA hiring said professional(s).
The Insured acknowledges that the PA has made no guarantees regarding the disposition or results of any stage of the claims process and all expressions made on behalf of the PA are the opinion of the PA based on information known at that time.
PA shall not be liable for property conditions or information pertinent to the claim not presented or requested by the Insured or the Insured’s contractor that are not included in the PA’s scope of professional services. PA shall undertake only the professional services required for the issues presented or requested by the Insured or Insured’s contractor, as determined by PA in its discretion.
The Insured represents that all information given to the PA is true and accurate. The Insured understands that pursuant to §.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 §.775.082, §.775.803, or §.775.084, Florida statutes. The Insured understands that the PA relies on the information provided by the Insured.
The undersigned (the Insured) hereby retains the above Public Insurance Adjuster, Florida’s Very Best Public Adjusters, Inc. (the PA) to be the Insured's representative in the adjustment of the above-referenced loss. The Insured understands and agrees that PA has retained Bulldog Adjusters, Inc. to provide administration services for all claims adjusted by PA including the Insured’s claim that is the subject of this Agreement. The Insured therefore understands and agrees that Bulldog Adjusters, Inc. will be entitled to receive a portion of the fees set forth below.
The Insured hereby agrees to pay to PA and Bulldog Adjusters, Inc., jointly, an amount equal to 10% of the gross amount of the collected loss or damage recovered regardless of whether the loss is settled or paid by the insurance company or by reason of the above referenced policy as a result of adjustment, mediation, appraisal, arbitration, lawsuit or otherwise, on all coverage applicable under the referenced policy or any other applicable policy, including, without limitation, claims for bad faith and extra-contractual damages or loss (hereafter referred to as the "PA fee"). If no recovery is made, the Insured will not be indebted to the Public Adjuster (PA) and Bulldog Adjusters Inc. for any sum of fees.
The Insured hereby authorizes the PA to contact the above-named insurance company to direct them to include the name of Bulldog Adjusters, Inc. as a payee on any and all insurance proceeds checks issued by reason of the above referenced loss. This provision shall remain in full force and effect unless revoked by mutual written agreement of the insured and PA.
Payment to the PA shall be due and payable in full at the time that insurance proceeds are paid or issued by the insurance company. In consideration for the PA's professional services, the Insured by this agreement hereby irrevocably assigns to the PA, and the PA shall have a lien on, the portion of the insurance proceeds paid or payable sufficient to pay the amount due the PA under the agreement. In the event legal proceedings are brought by the PA to enforce this agreement, the prevailing party shall be entitled to recover its court costs and reasonable attorney’s fee, including those of any appellate proceedings. Venue for all legal proceedings to be held in the courts of Broward County, Florida.
You, the insured, may cancel this contract for any reason without penalty or obligation to you within 10 days after the date of this contract by providing notice to Florida’s Very Best Public Adjusters, LLC. submitted in writing and sent by certified mail, return receipt requested or other form of mailing that provides proof thereof, at the address specified herein: 499 NW 70th Avenue, Suite 114, Plantation, Florida 33317.
The Insured hereby authorizes the PA to hire the professional services of appraisers, umpires, estimators, engineers, and any other experts as may be deemed necessary by the PA. Any costs associated with said claims recovery will be reimbursed to the PA. The Insured must consent to the cost prior to the PA hiring said professional(s).
The Insured acknowledges that the PA has made no guarantees regarding the disposition or results of any stage of the claims process and all expressions made on behalf of the PA are the opinion of the PA based on information known at that time.
PA shall not be liable for property conditions or information pertinent to the claim not presented or requested by the Insured or the Insured’s contractor that are not included in the PA’s scope of professional services. PA shall undertake only the professional services required for the issues presented or requested by the Insured or Insured’s contractor, as determined by PA in its discretion.
The Insured represents that all information given to the PA is true and accurate. The Insured understands that pursuant to §.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 §.775.082, §.775.803, or §.775.084, Florida statutes. The Insured understands that the PA relies on the information provided by the Insured.
Signature* Signature of Second Person on Policy (if applicable) Date*
MM slash DD slash YYYY
Stephen R. Lippy
LIC # P172086 03/22/2023
Howard A. Kornblatt
LIC # W332539 03/22/2023
Julian Leinhardt
LIC # W474003 03/22/2023
Sacha Ducrocq
LIC # W419679 03/22/2023
David Flaks
LIC # W322397 03/22/2023
Brennan Rimer
LIC # W322397 03/22/2023
Chris Gay
LIC # W183262 03/22/2023
