Mortgage Authorization Form Restored Loss Public Adjusters has been appointed by me to serve as my Public Adjuster for my insurance claim located at “Property Address of Insurance Claim”. I authorize any representative from Restored Loss Public Adjusters to discuss my loan, request inspections, and obtain branch endorsements on my behalf. In addition, I am requesting a payment be issued directly to Restored Loss Public Adjusters for their 20% portion of the claim proceeds for services rendered. I authorize the use of any prepaid Fedex envelopes provided to the address of Restored Loss Public Adjusters. Please mail the fee or any endorsed insurance checks and LOR disbursement checks to their office located at 5172 Birch Ave Sarasota, FL 34202.Select the cause of Damage(Required)Roof/ ExteriorDenied ClaimsFire DamageMold DamageWater DamageFlood DamageHVAC DamageVandalism/ TheftOtherType of Location:(Required)BusinessHomeBoatFarm/CropsMortgage CompanyLoan NumberProperty Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you the owner of Authorized to make decisions regarding your claim?(Required) Yes No Homeowner Name(Required) First Name Last Name Consent(Required) By Clicking This, you are e-signing this formDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time Hours : Minutes AM PM AM/PM Email for Copy(Required)
