Public Adjuster Contract Submission Form

Public Adjuster Contract Submission Form
Name of the Adjuster

First NameLast Name
License Number
Business Name
Name of the Insured

First NameLast Name
Business Name (if applicable)
Address of the Insured

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email of the Insured
example@example.com
Phone Number of the Insured
Please enter a valid phone number.Format: (000) 000-0000.
Date of the Loss

MonthDayYear
Date
Location of the Loss

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time of the Occurred

MonthDayYear
Date
Hour MinutesAM/PM Option
If you do not have the time occurrence, please explain why:
Type of Loss
Brief Description of The Type of Loss
Date And Time The Contract Was Signed

MonthDayYear
Date
Hour MinutesAM/PM Option
Location The Contract Signed

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was the insured provided a copy of the signed and completed contract?
How was the copy provided?
Was the contract submitted to the Maryland Insurance Administration within one business day of being signed?
Please attach the contract

Cancelof
By submitting this information, I hereby certify to the best of my knowledge, information, and belief, that the information to the Maryland Insurance Administration represents a full, complete and truthful response to the Maryland Insurance Commissioner's ("Commissioner") requirement for information in compliance with Section 10-414(f) of the Maryland Insurance Article. I further attest that I am an authorized officer/representative of any public adjuster business associated with the public adjuster contract being submitted, and I have undertaken an adequate inquiry to provide this certification to the Commissioner and am authorized to bind the public adjuster business to the responses provided.
Should be Empty: