Sec. 25.13. Exhibits

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 or partner, if any)

(time of initial contact)

 

(date of initial contact)

(name of insured)

 

hereby retains

 

(name of adjuster)

to act or aid in the preparation, presentation, adjustment and negotiation of or effecting the settlement of the claim for the loss or damage by

 

(nature of loss)

 

sustained at

 

(loss location) on ______, 19 __, and agrees to pay the adjuster for such services a fee of __percent of the amount of the loss including salvage when adjusted or otherwise recovered from the insurance companies.

NOTICE TO INSURED: PUBLIC ADJUSTERS MAY NOT CHARGE ANY INSURED FEES WHICH TOTAL MORE THAN 12 ½% OF THE RECOVERY FOR THE LOSS ADJUSTED BY SUCH ADJUSTERS.

THE FEE TO BE CHARGED UNDER THIS COMPENSATION AGREEMENT MAY BE NEGOTIATED BETWEEN THE PARTIES FOR LESS THAN 12½%.

A LOWER FEE THAN 12½% MAY BE NEGOTIATED WITH YOUR PUBLIC ADJUSTER. YOU, THE INSURED, SHOULD DISCUSS THE AMOUNT OF THE FEE WITH YOUR PUBLIC ADJUSTER BEFORE SIGNING ANY COMPENSATION AGREEMENT. THE AMOUNT YOU HAVE AGREED UPON MUST BE INITIALED BY YOU.

THIS COMPENSATION AGREEMENT IS VALID ONLY IF BOTH IT AND THE ATTACHED NOTICE OF CANCELLATION ARE WRITTEN IN THE SAME LANGUAGE AS THAT PRINCIPALLY USED IN THE ORAL NEGOTIATIONS AND PRESENTATION.

YOU MAY CANCEL THIS COMPENSATION AGREEMENT AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS COMPENSATION AGREEMENT. YOU SHOULD READ THE ATTACHED “NOTICE OF CANCELLATION” FORM FOR AN EXPLANATION OF THIS RIGHT.

NAME OF PUBLIC ADJUSTER OR LICENSED REPRESENTATIVE (Print)

SIGNATURE OF PUBLIC ADJUSTER OR LICENSED REPRESENTATIVE SIGNATURE OF INSURED

 

 

 

ADDRESS OF INSURED

TIME OR AGREEMENT DATE OF AGREEMENT

(b) Form 2.

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 CANCELLED.

TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE, OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM, TO:

______________

AT

 

 

(ADDRESS OF ADJUSTER)

(NAME OF ADJUSTOR)

NOT LATER THAN MIDNIGHT OF________

I HEREBY CANCEL THIS TRANSACTION.

DATE

(INSURED'S SIGNATURE)