Your Full Name:* (First and Last )
Telephone Numbers:* (Very important)
E-mail Address:* 
Insurance company(If unknown, just respond "not sure"): 
Policy number (if known): 
Please check any damage that you have noticed in your home. (Very important)
Drain or toilet backups?   
Water damaged walls, ceilings or floors?   
Raw sewage backing up out of drains?   
Foul smells (particularly a "rotten egg" smell)?   
Roach or rodent infestation?   
Leaks/water damage?   
Gurgling sounds coming from drains or toilets?   
Broken, cracked, tented (raised) and/or loose floor tiles?   
Stained, discolored tile grout?   
Water-stained or discolored carpet/rug mat?   
Discolored floor tile?   
Have you ever called plumber on this issue?              
If so when?   
Have you filed an insurance claim?              
What was the outcome?   
To assist us in negotiating a favorable settlement for you, please describe your damage. (Very important) 
Also, feel free to leave any comments:


By clicking the button below, I verify that all information provided above is correct,
I aver that I have authority to enter into this agreement, I consent to sign this application electronically, and I wish to submit this application for processing.

The undersigned (Insured) hereby retains Amloss Claims & Arbitration LLC. (AMLOSS) to be Insured’s agent and representative to appraise, advise, negotiate and/or adjust the above referenced loss under the following terms. Amloss is not a law firm and does not offer legal advice. Insured may wish to consult an attorney regarding their claim. Insured represents to Amloss and their insurance Company that they may have sustained damage to their property and instructs Amloss to file an insurance claim.

1. Scope of Services: Amloss will file insured’s claim with his/her insurance co., scope the loss, prepare an estimate of damages, prepare a Sworn Proof of Loss (SPOL) if required, and file same with insured’s carrier. Additionally, Amloss will attempt to adjust claim with carrier. Amloss will not select contractors to renovate or remediate.
2. Fees: The Insured hereby agrees to pay and irrevocably assigns to the Public Adjuster (PA) an amount equal to 20% (Twenty-percent) of the claim and recovery whether through adjustment, mediation, appraisal, arbitration, lawsuit or otherwise, on all coverages applicable under the referenced policy including claims for bad faith. However, for initial claims arising out of an occurrence declared an emergency by the State of Florida, the percentage shall be 10% (Ten-Percent) if this contract is executed within one year after the declaration of emergency for such occurrence directly related to this loss. If payment is made on a replacement cost value policy (RCV), the PA fee is based on the gross RCV adjustment/settlement/award.
3. Notice of assignment and payment: The Insured has assigned a portion of his/her claim to the PA and hereby authorizes and directs the above-named insurance company(s) to include the name of the PA as an additional payee on all insurance proceeds checks issued by reason of the above-referenced loss. Payment to the PA shall be due and payable in full at the time insurance proceeds are paid or issued by the insurance company. PA, at its discretion, may agree to accept a postdated check for its fee when PA indorses settlement check. In the event of any litigation instituted by the PA for non-payment of all or any part of the PA’s fee, the prevailing party on the issue of non-payment shall be entitled to recover reasonable attorney’s fees.
4. Insured Cooperation: The Insured agrees to comply with the PA’s and insurance company’s reasonable requests for information and other requirements of the insurance policy and the court.
5. Binding Effect: This agreement shall be binding on the Insured and the Insured’s personal representatives, executors and assigns.

All named insureds must sign this agreement. Pursuant to Florida Statute 626.8796 Client represents and warrants to Amloss that all named insureds are named and have signed this agreement.

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 written notice to Jacob Pollock, submitted in writing and sent by certified mail, return receipt requested, or other form of mailing that provides proof thereof, at the address specified in the contract.

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

The parties agree this Contract may be electronically signed and will have the same legal effect as a handwritten signature for the purposes of enforceability, validity and admissibility. Client may request a hard copy of this agreement to be signed manually instead of signing electronically by calling 954-652-1965.

Jacob Pollock public adjuster license number E141195

1975 East Sunrise Blvd., Suite 800, Fort Lauderdale, FI 33304
Toll-Free: 855-355-LOSS (5677)
Phone: 954-652-1965
Fax: 954-337-0120
Licensed & Bonded with the Florida Department of Financial Services
Email: admin@amloss.com

Thank you!

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