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Licensed and Bonded

Public Adjuster's Retainer Agreement

Licensed Public Insurance Adjusters 3048 4th Street, St. Augustine, FL 32084 · Tel: 1.904.501.4747 · Fax: 1.954.333.3638 · Email: [email protected] · Web:

THIS AGREEMENT is entered into this day of , 20 by and between, the "INSURED" and O'HANA ADJUSTING, LLC. The "INSURED" hereby retains O'HANA ADJUSTING, LLC a licensed public adjust firm to represent you in the adjustment and negotiation of his/her insurance claim for the loss or damages caused by on or about of , 20 at Address Client Home Number: Cell Phone Number: Work Number: Other Contact: Ins. Co. Phone: Policy # Claim # Payment Received $ In Consideration for the above described services, the "INSURED CLAIMANT" expressly agrees to pay O'HANA ADJUSTING, LLC the percentage of 20 % for all proceeds of all funds received in the settlement of his/her insurance claim regardless of whether the loss is settled or paid by the insurance company(s) as a result of adjustment, mediation, appraisal, arbitration, lawsuit or otherwise on all coverage's applicable under the described policy or any other applicable policy. The "INSURED/CLAIMANT" agrees to pay O'HANA ADJUSTING, LLC from the insurance proceeds any cost associated with the services performed necessary to settle this claim, including but not limited to: attorney, engineers, appraisers, or umpires. IF OHANA ADJUSTIING, LLC EXHAUSTS ALL MEANS TO COLLECT FROM THE INSURANCE COMPANY AND COLLECTS NOTHING THEN THE INSURED WILL OWE NOTHING TO O'HANA ADJUSTING, LLC. By signing below the policy holder states that all information given to O'HANA ADJUSTING, LLC is truthful and holds O'HANA ADJUSTING, LLC harmless and in all respects related to the above claim. The policy holder hereby authorizes and requests the insurance company that the name O'HANA ADJUSTING, LLC appears as a payee on all checks or drafts issued by the insurance company. In the event the insurance company that the name O'HANA ADJUSTING, LLC on the check, the policy holder hereby grants O'HANA ADJUSTING, LLC a lien on the recovered proceeds received by the policy holder to the extent of the fee due O'HANA ADJUSTING, LLC pursuant to this agreement. Moreover, this contract gives power to O'HANA ADJUSTING, LLC to deposit checks received from the insurance claim into O'HANA ADJUSTING, LLC escrow account, until such time as same clears. I, the INSURED/CLAIMANT authorize the mortgage company and/or bank to release a check of 20 % to O'HANA ADJUSTING, LLC as the only payee since they have rendered services to me and wish to their fee in advance should funds be dispersed partially and/or payments. O'HANA ADJUSTING, LLC agrees not to accept any settlement without discussion with and approval from the policy holder. This agreement shall be binding upon the estate of the insured in the event of his/her death. In the event of litigation arising out of this agreement, venue for such action shall be in DUVALL/ST JOHNS County, Florida and the prevailing party shall be entitled to recover its court costs and reasonable attorney fees, including those of any appealing proceedings. We authorize all funds and trenches to be sent to O'HANA ADJUSTING, LLC address listed above. The undersigned insured shall have the right to cancel by written document to O'HANA ADJUSTING, LLC this agreement within days following the date this document is signed. The notification must be sent to the office, certified mail and must be postmarked within the period stated above. By signing below the "INSURED/CLAIMANT" acknowledged he/she understands and accepts the terms of this agreement. O'HANA ADJUSTING, LLC O'HANA ADJUSTING, LLC (Signature) Public Adjuster License # Client's (Printed Name) Client's (Signature) Date Signed 3

Pursuant to s.817.234, Florida Statutes, any person who with the intent to injure, defraud, or deceive and 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, punishable in provided in s. 775.082, s. 775.083, s. 775.084, Florida Statutes.

Licensed and Bonded

Public Adjuster's Retainer Agreement


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