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Public Adjuster Contract & Letter of Representation

Grossman PA LLC
Insurance Claims Specialists
Claimhelpme.com

Name

First Name

Last Name

Insurance Contract Provider

Claim Number

Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Loss

Reason

Checkbox

New claim

Supplemental claim

Non-Emergency claim

Emergency claim

Re-Open

Notice of Cancellation

(The insured/policy holder agrees to pay to Mark Grossman., __5__% of the total amount after the deductible of the actual loss or damages recovered by adjustment, mediation, appraisal, or litigation including but not limited to building, personal property, A.L.E., loss of income or business interruption. Fee shall be immediately due and payable upon insurance company making any payment. In addition, the insured/policy holder authorizes Mark Grossman to be named as one of the payees on all insurance benefits checks issued on this claim. Services can or may include, but are not limited to, filing the insurance claim, meeting with the Insurance company representative, writing the estimate of the structure damages and contents, filling out and filing a Sworn Proof of Loss, conferences with client, keeping client informed as to status of claim, reviewing the insurance policy, etc. when and if needed as deemed by the Public Adjuster. This agreement shall be governed by and enforced in accordance with the laws of the state of New York. If a dispute arises with respect to the informed party with this agreement, and any legal proceedings shall be brought to enforce or interpret any provisions in this document, or to recover damage or breach of this agreement, the parties waive the right to a jury trial. The parties agree and consent to resolve all disputes regarding this agreement by arbitration. The losing party shall reimburse the other party for his/ her/its reasonable attorney fees and costs. The above named insured will cooperate with Mark Grossman in pursuing this claim, including timely executing and providing such documents as Mark Grossman may request from time to time. CANCELLATION OF AGREEMENT: POLICYHOLDER may cancel this Agreement without penalty or obligation within three (3) business days after the date on which this Agreement is executed, as shown below, or within three (3) business days after the date on which POLICYHOLDER or Mark Grossman or the PUBLIC ADJUSTER has notified any insurance company of the claim, by phone or in writing, whichever is later. The notice of cancellation must be submitted in writing and sent by certified mail, return receipt requested, or other form of mailing that provides proof of mailing thereof to the Mark Grossman at the address specified below.) By initialing here

Pursuant to New York 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.

Policy Holder Name

Date

YYYY

Time

Hour

Minute

Second

Policy Holder Name

Date

YYYY

Time

Hour

Minute

Second

Public ADJUSTER Name

New York License # 1804459

Date

YYYY

Time

Hour

Minute

Second

Mark Grossman, President

NOTICE OF CANCELLATION

YOU MAY CANCEL THIS COMPENSATION AGREEMENT, WITHOUT ANY PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL ANY PAYMENTS MADE BY YOU UNDER THE 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 CANCELED. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE, OR ANY OTHER WRITTEN NOTICE, OR SEND VIA CERTIFIED MAIL TO: Mark Grossman at Grossman PA LLC, 24 Comanche Lane, Commack, NY 11725 NOT LATER THAN MIDNIGHT OF

Date

YYYY

Time

Hour

Minute

Second

Name

INSURED

POLICY No

DATE OF LOSS

YYYY

DIRECTION TO PAY

The New York State Insurance Law Regulation 10, 3rd Amendment (11 YC RR 25.12) States as follows: “25.12 PAYMENT OF LOSSES: WHEN A CLAIM IS SETTLED WHERE THE INSURED IS REPRESENTED BY A PUBLIC ADJUSTER, UPON REQUEST BY THE INSURED, THE INSURERS CHECK MAY BE MADE PAYABLE TO BOTH THE PUBLIC ADJUSTER AND THE INSURED OR TO THE PUBLIC ADJUSTER NAMED AS THE PAYEE, BUT NOT IN EXCESS OF THE AMOUNT OF THE ADJUSTERS FEE, AS INDICATED IN THE WRITTEN COMPENSATION AGREEMENT SIGNED BY THE ASSURED AND FILED WITH THE INSURER, THE BALANCE OF THE PROCEEDS SHALL BE MADE PAYABLE TO THE INSURED OR THE LOSS PAYEE, OR BOTH, WHICHEVER IS APPROPRIATE”. IN ACCORDANCE WITH THE LAW, PLEASE CHECK THE LINE OF YOUR CHOICE AND SIGN WHERE INDICATED: A CHECK MADE PAYABLE TO BOTH THE PUBLIC ADJUSTER AND THE NAMED INSURED (FOR AN AMOUNT NO GREATER THAN THE PUBLIC ADJUSTERS FEE). A CHECK MADE PAYABLE TO THE NAMED INSURED IN THE AMOUNT OF THE BALANCE PAYABLE. A CHECK MADE PAYABLE TO Contractor IN THE AMOUNT OF TBD FOR BALANCE OF REPAIRS.

A CHECK MADE PAYABLE TO GROSSMAN PA LLC. IN THE AMOUNT OF

Date

YYYY

INSURED’S Name

Date

YYYY

INSURED’S Name

Mark Grossman NY license# PA-1804459
Grossman PA LLC
24 Comanche Ln, Commack, NY 11725 Office: (516) 807-6091
admin@grossmanpa.com

Finalize Your Claim Support with Confidence

Public Adjuster Contract & Letter of Representation

Grossman Public Adjusters

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