New Client Contract

Client Area >> Bradford Starnes >> New Contract

This is your Letter of Representation (Contract), which allows Dorsten Claims to work on your behalf with your Insurance Company. Please provide your Name, Address, Phone Number, Insurance Company and either a Claim Number or Policy Number.

PUBLIC ADJUSTER: BRADFORD STARNES
LICENSE# W162733

Your Name *

Your Insurance Company *

The best phone number to reach you *

Your Email *

Claim #

Policy #

Type of Claim *

State of Emergency? *

Property Address (Location of the Loss) *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Loss *

Cause of Loss *

Please select one of the following *

I have NOT received the first check from my insurance company (NEW)
I have received the first check from my insurance company (SUPPLEMENTAL)

Disclaimer

“Pursuant to s. 817. 234, Florida 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, punishable as provided in s. 775.082, s.775.803, or s.775.084, Florida statutes.”

Cancellation

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 notice to Mark Dorsten at Dorsten Claims LLC, 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.

Dorsten Claims LLC, 13304 Airway St. Panama City, FL 32404

I have read and understand the above required disclaimer and cancellation clause *

IMPORTANT NOTE: If there is more than one person appearing on the policy each person must complete and execute this form. It is a legal necessity. Having each person fill out the contract does not change the fee. It remains the same but the insurance companies must have a signature from all the people on the Policy. Please call if you have any questions.

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