(Date of initial contact) ___________ (Time of initial contact) ___________

(Name of Named Insured[s]) (the “Insured”), residing at (Address), hereby retains (Public Adjuster’s Name) (the “Adjuster”) to act or aid in the preparation, presentation, adjustment, and negotiation, or effecting the settlement, of the claim for the loss or damage by a covered peril or perils sustained at (Loss Location) on (Date of Loss), and agrees to pay the Adjuster for such service a fee of (Number) percent of the amount of the loss, including salvage, when adjusted or otherwise recovered from the insurance companies.

(Number) disclosure statements are attached hereto.

1. The Adjuster may not receive any compensation unless the Adjuster discloses the compensation to you.

2. The Adjuster may not charge you any fees that total more than 12.5% of the recovery for services rendered by the Adjuster, except that the Adjuster may charge a fee of up to 20% on a supplemental claim if the aggregate fee charged is less than or equal to 12.5% of the full claim payment. A supplemental claim is a claim made to an insurer in a situation in which you did not retain a public adjuster when you made an initial claim, the insurer made a payment to you, and then you retained a public adjuster to prove the amount of the loss and extent of the loss and not the cause of the loss.

A. The limit on the total fees that may be charged includes services rendered by an outside expert or consultant retained or employed by the Adjuster that directly relate to the adjusting function of the Adjuster.

B. The limit on total fees also includes any referral of an individual or entity for services, work, or repairs relating to any insurance claim for which the Adjuster represents or represented you or has negotiated or effected a settlement.

C. If the Adjuster refers you to an individual or entity, including after you sign this compensation agreement, then the Adjuster must obtain an acknowledged disclosure statement from you at the time of the referral.

D. YOU ARE NOT REQUIRED TO USE ANY INDIVIDUAL OR ENTITY TO WHOM OR WHICH THE ADJUSTER REFERS YOU.

3. The Adjuster must compute the fee based upon any monies paid by the insurer for any insurance claim for which the public adjuster represents or represented you or has negotiated or effected a settlement, after you have retained the Adjuster’s services.

4. The fee to be charged under this compensation agreement may be negotiated between the parties for less than 12.5%, or with regard to a supplemental claim, for less than 20%. You should discuss the amount of the fee with the Adjuster before signing any compensation agreement. You must initial the amount upon which you have agreed.

5. This compensation agreement is valid only if both this agreement and the attached notice of cancellation are written in the same language as that principally used in the oral negotiations and presentation.

6. You may cancel this compensation agreement at any time prior to midnight of the third business day after you signed this compensation agreement. Please read the attached “Notice of Cancellation” form for an explanation of this right.

(Public Adjuster’s Name) (the “Adjuster”) referred (Name of Named Insured[s]) (the “Insured”), residing at (Address), to (Name and Address of Individual or Entity) for services, work, or repairs, relating to an insurance claim for which the Adjuster represents or represented the Insured or has negotiated or effected a settlement.

The Adjuster shall check off any and all applicable boxes:

□ The Adjuster has received or will receive the following compensation for the referral:

(Specify the dollar amount or percentage. If compensation is in the form of anything other than money, then state the nature of the compensation and its approximate fair market value.)

□ The Adjuster and/or his or her spouse has a financial or ownership interest, directly or indirectly, in the individual or entity listed above.

□ The Adjuster is related to the individual listed above by blood or affinity within the second degree of consanguinity (which includes an individual’s parents, grandparents, children, grandchildren, siblings, and any spouse thereof).

□ The entity listed above is owned or controlled by an individual who is related to the Adjuster by blood or affinity within the second degree of consanguinity (which includes an individual’s parents, grandparents, children, grandchildren, siblings, and any spouse thereof).

NOTICE TO INSURED: YOU ARE NOT REQUIRED TO USE ANY INDIVIDUAL OR ENTITY TO WHOM OR WHICH THE PUBLIC ADJUSTER REFERS YOU.

This disclosure statement must be written in the same language as that principally used in the oral negotiations and presentation.

You may cancel the written compensation agreement, without any penalty or obligation, until midnight of the third business day after the date on which you signed the compensation agreement.

If you cancel, then any payments made by you under the compensation 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, to (Name and Address of Public Adjuster) no later than midnight of (Date).

Name(s) of Named Insured(s):

Policy No.:

Claim No.:

Public Adjuster’s Name:

I hereby direct (Name of Insurer) to issue a check or checks as follows:

□ one check payable to the public adjuster for the public adjuster’s fee indicated in the written compensation agreement signed by the named insured(s) and filed with the insurer, less any referral fee set forth in a disclosure statement, if applicable, and a separate check payable to the named insured(s) or any loss payee or mortgagee, or both, whichever is appropriate, for the balance.

□ one check payable to both the public adjuster and named insured(s) for the public adjuster’s fee indicated in the written compensation agreement signed by the named insured(s) and filed with the insurer, less any referral fee set forth in a disclosure statement, if applicable, and a separate check payable to the named insured(s) or any loss payee or mortgagee, or both, whichever is appropriate, for the balance.

NOTICE TO NAMED INSURED(S): You may revoke this direction to pay letter at any time prior to the insurer issuing a check. Your revocation must be in writing and signed by you. You must submit the revocation to the insurer and provide the public adjuster with a copy.