Online Registration

Name: ROOF LEAK
Brand: Bulldog Adjusters
Availability: InStock
Rating: 4.4 (89 reviews)

Full Name*
Phone*
Email Address
Address*
Street Address City ZIP Code
State*
State
Homeowners Insurance Company
Mortgage Company
Policy Number*
Claim Type*
Date of Loss*
Cause of Loss
Please provide as much detail as necessary to explain the cause of loss or damage to your home.

Adjuster Name
Photos of Damage
Please upload any photos of damage that you may have available.
Drop files here or

Letter of Representation

FEMA 400 C Street SW, 3rd Floor SW Washington DC 20472-3010

Authorized Representative: Bulldog Adjusters Inc.

To Whom It May Concern,
I expressly grant permission to FEMA to release my records to this third-party representative.
County of:
"I declare under penalty of perjury that the foregoing is true and correct.
Executed on:
(Pursuant to 28 U.S.C.S 1746).
Print Name:
Signature
Print Name:
Disclosure Agreement
As presented in RS 22.1704:
Property insurance policies obligate the insured to present a claim to his insurance company for consideration. There are three types of adjusters that could be involved in that process. The definitions of the three types are as follows:
(a) "Company adjusters" means the insurance adjusters who are employees of an insurance company. They represent the interest of the insurance company and are paid by the insurance company. Company adjusters shall not charge insureds a fee.
(b) "Independent adjusters" means the insurance adjusters who are hired on a contract basis by an insurance company to represent the insurance company's interest. They are paid by your insurance company. Independent adjusters shall not charge insureds a fee.
(c) "Public adjusters" means the insurance adjusters who do not work for any insurance company. They work for the insured to assist in the investigation, appraisal, evaluation, and reporting of the claim. The insured hires them by signing a contract agreeing to pay them a fee.
(2) The insured is not required to hire a public adjuster to help the insured meet his obligations under the policy but has the right to do so.
(3) The insured always has the right to initiate direct communications with the insured's attorney, the insurer, the insurer's adjuster, and the insurer's attorney, or any other person regarding the settlement of the insured's claim. Once a public adjuster has been retained, the public adjuster shall not restrict communications between the insurer and its insured.
(4) The public adjuster is not a representative or employee of the insurer.
(5) The salary, fee, or other consideration to be paid to the public adjuster is the obligation of the insured, not the insurer.
F. The contracts shall be executed in duplicate to provide an original contract to the public adjuster and an original contract to the insured. The public adjuster's original contract shall be available at all times for inspection without notice by the commissioner of insurance.
G. The public adjuster shall provide the insurer a notification letter, which has been signed by the insured, indicating that the insured and the public adjuster have a contract pursuant to this Part. Delivery of this letter shall not prohibit or impede the right of the insured to communicate directly with the insurer.
H. The insured has the right to rescind the contract within three business days after the date the contract was signed. The rescission shall be in writing and mailed or delivered to the public adjuster at the address in the contract within the three business day period.
I. If the insured exercises the right to rescind the contract, any thing of value given by the insured under the contract will be returned to the insured within fifteen business days following the receipt by the public adjuster of the cancellation notice.
J. The contract shall not be construed to prevent an insured from pursuing any civil or judicial remedy.
Agree to the above Disclosure Agreement*
- Agree
- Disagree

The undersigned (the Insured) hereby retains the above Public Insurance Adjuster, Bulldog Adjusters Inc (the PA) to be the Insured's representative in the adjustment of the above referenced loss under the following terms: The Insured hereby agrees to pay to the PA an amount equal to 20% of the gross amount of the collected loss or damage recovered regardless of whether the loss is settled 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 PA 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. This contract may be cancelled by written notification to the PA, sent by certified mail, return receipt requested or other form of mailing which provides proof thereof, at any time within three (3) business days of the date the contract was signed, as shown above, and if canceled the Insured shall not be obligated to pay any fees to the PA, for the work performed during that time. If the PA has advanced funds or has made payments on behalf of the Insured to others, in representation of the insured, the PA, is entitled to be reimburse for such amounts as it has reasonably advanced on behalf of the Insured. In the event that this contract is canceled by the Insured after three (3) business days, then the PA shall have a retaining lien and charging lien for work performed and costs advanced. Furthermore, the PA will not be held liable in any way for any filed claims on the property which were canceled by the Insured. If the insured exercises the right to rescind the contract, anything of value given by the insured under the contract will be returned to the insured within 15 business days following the receipt by the public adjuster of the cancellation notice. 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 reimburse to the PA. The Insured must consent to the cost prior to the PA hiring said professional(s). The Insured understands that it is responsible to pay the PA its fee, out of any and all insurance proceeds, prior to any payments to anyone else, including but not limited to mortgage companies, insurance companies, lenders, creditors, or any third parties, of any kind, or any other individual or corporation. The Insured hereby agrees that the Insured is solely responsible to timely obtain any and all mortgage endorsements necessary of said payments/checks so as to release payments to the PA. The PA shall in no event be obligated to conform to mortgage company requirements, in order to receive agreed to fee payments, and or out of pocket reimbursements. ________ _______ 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. The Insured understands that prior to initiating any contact with the insured's insurer, the insurer's adjuster, or the insurer's attorney regarding settlement of the insured's claim, a PA must provide the insurer a notification letter signed by the insured confirming that the insured has authorized the PA to communicate directly with the insurer, the insurer's adjuster, or the insurer's attorney on behalf of the insured. The Insured understands that this document must be signed prior to the PA initiating any contact with the insured's insurer, the insurer's adjuster, or the insurer's attorney regarding settlement of the insured's claim. This document will serve as a notification letter signed by the insured confirming that the insured has authorized the PA to communicate directly with the insurer, the insurer's adjuster, or the insurer's attorney on behalf of the insured. The Insured represents that all information given to the PA is true and accurate. 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, Bulldog Adjusters Inc (the PA), located at 6950 Cypress Road STE 300 Plantation, FL 33317 and reached at (786) 230-4741, to be the Insured's representative in the adjustment of the above referenced loss under the following terms:

The Insured hereby agrees to pay to the PA a reasonable hourly fee not to exceed 10% of the loss 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").

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.

This contract may be cancelled by written notification to the PA, sent by certified mail, return receipt requested or other form of mailing which provides proof thereof, at any time within three (3) business days of the date the contract was signed, as shown above, and if canceled the Insured shall not be obligated to pay any fees to the PA, for the work performed during that time. If the PA has advanced funds or has made payments on behalf of the Insured to others, in representation of the insured, the PA, is entitled to be reimburse for such amounts as it has reasonably advanced on behalf of the Insured. In the event that this contract is canceled by the Insured after three (3) business days, then the PA shall have a retaining lien and charging lien for work performed and costs advanced. Furthermore the PA will not be held liable in any way for any filed claims on the property which were canceled by the Insured.

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 reimburse to the PA. The Insured must consent to the cost prior to the PA hiring said professional(s).

The Insured understands that it is responsible to pay the PA its fee, out of any and all insurance proceeds, prior to any payments to anyone else, including but not limited to mortgage companies, insurance companies, lenders, creditors, or any third parties, of any kind, or any other individual or corporation. The Insured hereby agrees that the Insured is solely responsible to timely obtain any and all mortgage endorsements necessary of said payments/checks so as to release payments to the PA. The PA shall in no event be obligated to conform to mortgage company requirements, in order to receive agreed to fee payments, and or out of pocket reimbursements.

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.

The Insured represents that all information given to the PA is true and accurate. The Insured understands that pursuant to RS.22.1924, Louisiana statutes, any person who, with the intent to injure, defraud, or deceive any insurance company, or the Department of Insurance, or any insured or other party in interest, or any third-party claimant commits any fraudulent insurance act as defined in R.S. 22:1923 is guilty of a felony and is punishable as provided in RS.22:1924, Louisiana statues. 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, Bulldog Adjusters Inc (the PA) to be the Insured's representative in the adjustment of the above referenced loss under the following terms:

The Insured hereby agrees to pay to the PA an amount equal to 20% of the gross amount of the collected loss or damage recovered regardless of whether the loss is settled 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 PA 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.

This contract may be cancelled by written notification to the PA, sent by certified mail, return receipt requested or other form of mailing which provides proof thereof, at any time within three (3) business days of the date the contract was signed, as shown above, and if canceled the Insured shall not be obligated to pay any fees to the PA, for the work performed during that time. If the PA has advanced funds or has made payments on behalf of the Insured to others, in representation of the insured, the PA, is entitled to be reimburse for such amounts as it has reasonably advanced on behalf of the Insured. In the event that this contract is canceled by the Insured after three (3) business days, then the PA shall have a retaining lien and charging lien for work performed and costs advanced. Furthermore the PA will not be held liable in any way for any filed claims on the property which were canceled by the Insured.

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 reimburse to the PA. The Insured must consent to the cost prior to the PA hiring said professional(s).

The Insured understands that it is responsible to pay the PA its fee, out of any and all insurance proceeds, prior to any payments to anyone else, including but not limited to mortgage companies, insurance companies, lenders, creditors, or any third parties, of any kind, or any other individual or corporation. The Insured hereby agrees that the Insured is solely responsible to timely obtain any and all mortgage endorsements necessary of said payments/checks so as to release payments to the PA. The PA shall in no event be obligated to conform to mortgage company requirements, in order to receive agreed to fee payments, and or out of pocket reimbursements.

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.

The Insured represents that all information given to the PA is true and accurate. The Insured understands 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 statutes. The Insured understands that the PA relies on the information provided by the Insured.
Insured Signature
Date
Insured Signature:*
Date
P.A.
Date*
Adjuster Name Georgia
Licensed and Bonded in the State of Georgia since 06/04/2018
Licensed and Bonded in the State of Georgia since 06/07/2016
Comments
This field is for validation purposes and should be left unchanged.

Disclosure Agreement