The following forms are hereby approved for use as specified
in this Part:
(a) Form 1.
PUBLIC ADJUSTER
COMPENSATION AGREEMENT
[Name and Address of Public Adjuster]
_________________________
Name of sublicensee
Date of initial contact: __________________ Time of initial
contact: ___________________
(Number) disclosure statements are attached hereto.
NOTICE TO INSURED
1.
The Adjuster may not receive any compensation unless the Adjuster discloses the
compensation to you.
2. The
Adjuster may not charge you any fees that total more than 12.5% of the recovery
for services rendered by the Adjuster, except that the Adjuster may charge a
fee of up to 20% on a
supplemental claim if the aggregate fee charged is less
than or equal to 12.5% of the full claim payment. A
supplemental claim is a
claim made to an insurer in a situation in which you did not retain a public
adjuster when you made an initial claim, the insurer made a payment to you, and
then you retained a public adjuster to prove the amount of the loss and extent
of the loss and not the cause of the loss.
A.
The limit on the total fees that may be charged includes services rendered by
an outside expert or consultant retained or employed by the Adjuster that
directly relate to the adjusting function of the Adjuster.
B. The limit on total fees also includes any
referral of an individual or entity for services, work, or repairs relating to
any insurance claim for which the Adjuster represents or represented you or has
negotiated or effected a settlement.
C. If the Adjuster refers you to an
individual or entity, including after you sign this compensation agreement,
then the Adjuster must obtain an acknowledged disclosure statement from you at
the time of the referral.
D. YOU
ARE NOT REQUIRED TO USE ANY INDIVIDUAL OR ENTITY TO WHOM OR WHICH THE ADJUSTER
REFERS YOU.
3. The
Adjuster must compute the fee based upon any monies paid by the insurer for any
insurance claim for which the public adjuster represents or represented you or
has negotiated or effected a settlement, after you have retained the Adjuster's
services.
4. The fee to be charged
under this compensation agreement may be negotiated between the parties for
less than 12.5%, or with regard to a supplemental claim, for less than 20%. You
should discuss the amount of the fee with the Adjuster before signing any
compensation agreement. You must initial the amount upon which you have
agreed.
5. This compensation
agreement is valid only if both this agreement and the attached notice of
cancellation are written in the same language as that principally used in the
oral negotiations and presentation.
6. You may cancel this compensation agreement
at any time prior to midnight of the third
business day after you signed this
compensation agreement. Please read the attached "Notice of Cancellation" form
for an explanation of this right.
_____________________ _______________________
Signature of Public Adjuster Signature of Named
Insured(s)
or Licensed Representative Thereof
Date: _________________ Time:
_________________
(b) Form 2.
DISCLOSURE STATEMENT
[Name and Address of Public Adjuster]
_________________
Name of sublicensee
The Adjuster shall check off any and all applicable
boxes:
[] The Adjuster has received or will receive the following
compensation for the referral:
__________________________________________________________________
__________________________________________________________________
(Specify the dollar amount or percentage. If compensation is
in the form of anything other than money, then state the nature of the
compensation and its approximate fair market value.)
[] The Adjuster and/or his or her spouse has a financial or
ownership interest, directly or indirectly, in the individual or entity listed
above.
[] The Adjuster is related to the individual listed above by
blood or affinity within the second degree of consanguinity (which includes an
individual's parents, grandparents, children, grandchildren, siblings, and any
spouse thereof).
[] The entity listed above is owned or controlled by an
individual who is related to the Adjuster by blood or affinity within the
second degree of consanguinity (which includes an individual's parents,
grandparents, children, grandchildren, siblings, and any spouse
thereof).
NOTICE TO INSURED: YOU ARE NOT REQUIRED TO USE ANY INDIVIDUAL
OR ENTITY TO WHOM OR WHICH THE PUBLIC ADJUSTER REFERS YOU.
This disclosure statement must be written in the same
language as that principally used in the oral negotiations and
presentation.
_____________________ ________________________
Signature of Public Adjuster Signature of Named
Insured(s)
or Licensed Representative
Date: _________________ Time:
_________________
(c) Form
3.
NOTICE OF CANCELLATION
You may cancel the written compensation agreement, without
any penalty or obligation, until midnight of the third business day after the
date on which you signed the compensation agreement.
If you cancel, then any payments made by you under the
compensation agreement, and any negotiable instrument executed by you, will be
returned within ten business days following receipt by the public adjuster of
your cancellation notice, and any security interest arising out of the
transaction will be cancelled.
To cancel this transaction, mail or deliver a signed and
dated copy of this cancellation notice, or any other written notice, to (Name
and Address of Public Adjuster) no later than midnight of (Date).
I hereby cancel this transaction.
_________________________ _____
Signature(s) of Named Insured(s) Date
(d) Form 4.
DIRECTION TO PAY LETTER
Name(s) of Named Insured(s):
___________________________________________________________
Policy No.:
_______________________________________________________________________________
Claim No.:
_____________________________________________________________________________
Public Adjuster's Name:
________________________________________________________________
I hereby direct (Name of Insurer) to issue a check or checks
as follows:
[] one check payable to the public adjuster for the public
adjuster's fee indicated in the written compensation agreement signed by the
named insured(s) and filed with the insurer, less any referral fee set forth in
a disclosure statement, if applicable, and a separate check payable to the
named insured(s) or any loss payee or mortgagee, or both, whichever is
appropriate, for the balance.
[] one check payable to both the public adjuster and named
insured(s) for the public adjuster's fee indicated in the written compensation
agreement signed by the named insured(s) and filed with the insurer, less any
referral fee set forth in a disclosure statement, if applicable, and a separate
check payable to the named insured(s) or any loss payee or mortgagee, or both,
whichever is appropriate, for the balance.
NOTICE TO NAMED INSURED(S): You may revoke this direction to
pay letter at any time prior to the insurer issuing a check. Your revocation
must be in writing and signed by you. You must submit the revocation to the
insurer and provide the public adjuster with a copy.
_________________________ _____
Signature(s) of Named Insured(s)
Date
