Public Adjuster Contract Submission Form
Name of the Adjuster
*
First Name
Last Name
License Number
*
Business Name
*
Name of the Insured
*
First Name
Last Name
Business Name (if applicable)
Address of the Insured
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email of the Insured
*
example@example.com
Phone Number of the Insured
*
Please enter a valid phone number.
Date of the Loss
*
-
Month
-
Day
Year
Date
Location of the Loss
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Time of the Occurred
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
If you do not have the time occurrence, please explain why:
Type of Loss
*
Please Select
Commercial
Personal
Brief Description of The Type of Loss
*
Date And Time The Contract Was Signed
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location The Contract Signed
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Was the insured provided a copy of the signed and completed contract?
*
Yes
No
How was the copy provided?
*
Was the contract submitted to the Maryland Insurance Administration within one business day of being signed?
*
Yes
No
Please attach the contract
*
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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.
*
Agree
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