To secure the services of apex public adjusting,

please complete the information below.

APEX Public Adjusting works for you, the property owner, to make sure you are paid fairly by the insurance company on your claim. There is no upfront cost for our services. We are only paid on a contingency basis after the deductible has been met and you are paid.

We provide concierge style, white glove service & open communication with our clients

POLICY HOLDER INFORMATION

Name ("the Policyholder")

First Name

Last Name

Phone

(###)

###

####

Name of second person on policy ("the Policyholder")

First Name

Last Name

Phone of second person

(###)

###

####

Address of Insured Property (the "Property")

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Insured Property

House

Condominium

Commercial Property

POLICY CLAIM INFORMATION

Homeowner Insurance Company ("the Insurer")

Policy Number ("the Policy")

Claim Type

Did you already call the claim in?

Yes

If Yes, what is claim number? ("the Claim")

In Dollars, what is the Amount of your Deductible?

If you are uncertain, please attach a copy of your coverage (dec page) after submitting form.

Date of Loss

YYYY

Cause of Loss and Damage Description

Please be as detailed as possible explaining the cause of loss and the damage to the insured property.

Additional Notes

The Policyholder(s), as referred to above, hereby agree to retain APEX Public Adjusting Inc. ("the PA") to be the Policyholder's representative in the adjustment of the above referenced loss under the following terms: ThePolicyholder 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 and paid by the insurer 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 TOTAL CONTRACTUAL PERCENTAGE SHALL NOT EXCEED THE MAXIMUM ALLOWED BY LAW. IF NO RECOVERY IS MADE, THE POLICYHOLDER WILL NOT BE INDEBTED TO THE PA FOR ANY SUM OF FEES. The Policyholder(s) hereby authorize the PA to contact the above named Insurer to direct them to include the name of APEX Public Adjusting, 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 Policyholder 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 insurer. In consideration for the PA's professional services, the Policyholder 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. During any state of emergency as declared by the Governor and for 1 year after the date of loss, the insured or claimant has five (5) business days after the date on which the contract is executed to cancel a public adjuster’s contract. This contract may be canceled 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 five (5) business days of the date the contract was signed, as shown above, and if canceled the Policyholder 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 Policyholder to others, in representation of the Policyholder, the PA, is entitled to be reimbursed for such amounts as it has reasonably advanced on behalf of the Policyholder. In the event that this contract is canceled by the Policyholder after five (5) 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 Policyholder. The Policyholder hereby authorizes the PA to hire professional services of estimators, engineers, appraisers, umpires, and any other experts deemed necessary by the PA. The Policyholder 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 Policyholder 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. 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 Policyholder represents that all information given to the PA is true and accurate. The Policyholder understands “Pursuant to s.817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive an 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 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.775.083, or s.775.084, Florida Statutes.

Today's Date

YYYY

Acknowledgement by Policyholder(s) : By hitting the "SUBMIT" button below, the above named Policyholder(s) enter into this agreement with Apex Public Adjusting Inc. Following submission, and once received by the PA, the licensed public adjuster assigned will sign, date and send back a fully executed agreement.

I/We The Policyholder(s)Understand and Agree

***Submitting Documents (can be done later)*** After submitting your form, you will be directed back to a link where you can then attach any files. When you click on the link, it will open an email window whose address will be: ClaimRegistration@Apexpublicadjusting.com

If you would like to upload a copy of your insurance declaration page along with any photos you have of the damages, as well as correspondence with your insurance company, please use the link supplied in the next window.