Authorization Form

I do hereby retain Southern Claim Adjusters LLC to be my agent and representative to assist in the preparation, presentation, and adjustment of all applicable claims for the loss or damage listed above. Southern Claim Adjusters LLC is hereby hired as a Public Adjuster and is obligated under our Public Adjuster licenses to serve with objectivity and complete loyalty to the interest of our client alone and to render to the insured such information, counsel, and service within Southern Claim Adjusters LLC’S knowledge, understanding, and opinion that will best serve the insured’s insurance claim needs and interest pursuant to O.C.G.A. § 33-23- 43.2.

The duties of the Public Adjuster shall be limited to assisting in proving the loss and coverage where applicable by the first named insured’s policy and determining the value of the loss covered by that same policy. Insured agrees to assist Southern Claim Adjusters LLC in the processing of the insured’s claim. All information given by the insured to Southern Claim Adjusters LLC will be presumed to be true. The insured agrees to pay Southern Claim Adjusters LLC for such services,

of the amount collected, adjusted, or otherwise received and/or issued by the involved Insurance Carrier plus expenses, direct costs, or any other costs accrued by Southern Claim Adjusters LLC outside of the normal course of business. Expenses may include but are not limited to appraisal fees, engineer fees, satellite imagery costs and/or other related costs. No related expenses or costs will be charged to the insured unless agreed to in writing prior to incurring the associated fees. Southern Claim Adjusters LLC’S fee shall be due as a percentage of each draft or check when collected from the insurance carrier at the rate listed in this contract.

Interest Disclosure: The public adjuster does not have any direct or indirect interest in or compensation by any construction firm, salvage firm, building appraisal firm, storage company, or any other firm or business entity that performs any work in conjunction with damages incident to any loss which the adjuster has been contracted to adjust. The public adjuster does not have any direct or indirect participation in the reconstruction, repair, or restoration of damaged property that is the subject of a claim adjusted by the adjuster or disclosure of any other activities that may be reasonably construed as a conflict of interest, including a financial interest in any salvage, repair, construction, or restoration of any business entity that obtains business in connection with any claims that the public adjuster has a contract or agreement to adjust (which is specifically prohibited in 33-23-43.8 (g)). The public adjuster does not have any direct or indirect compensation of value in connection with an insured’s specific loss other than compensation from the insured for service as a public adjuster.

We Represent the Insured Only
Payment Disclosure: Insured may direct Southern Claim Adjusters LLC to make disbursements to 3rd party contractor(s) on behalf of the insured from insurance drafts and checks upon receipt of such payments from the insurer for work contracted to be performed or work completed by the contractor related to the claim. If a direction of pay is requested, the insured will remain an endorsee on the draft. Prior to initiating any contact with the insured’s insurer, the insurer’s adjuster, or the insurer’s attorney regarding settlement of the insured’s claim, a public adjuster must provide the insurer a notification letter signed by the insured confirming that the insured has authorized the public adjuster to communicate directly with the insurer, the insurer’s adjuster, or the insurer’s attorney on behalf of the insured. This agreement does not restrict the insured’s right to initiate and maintain direct communications with the insured’s attorney, the insurer, the insurer’s adjuster, the insurer’s attorney, or any other person regarding settlement of the insured’s claim or from pursuing any civil remedies relating to the claim.

Authorization to Endorse on Behalf of Insured: Insured authorizes Southern Claim Adjusters LLC to sign or endorse a payment, draft, or check issued on behalf of the insured. This authorization is limited to the endorsement of the check or payment for deposit only into Southern Claim Adjusters LLC’S escrow or trust account. The check or payment will be distributed in the percentages or amounts agreed upon in this contract. The insured will be notified of the deposit of funds. Any distribution of such funds to the insured or Southern Claim Adjusters LLC will be accompanied by a detailed breakdown of the funds distributed. This authorization may be revoked at any time by the insured upon written notice of such revocation to Southern Claim Adjusters LLC pursuant to O.C.G.A. 33-23-43.3(e).

By signing this agreement, the insured hereby authorizes Southern Claim Adjusters LLC to initiate and maintain communication with the insurer and its representatives on behalf of the insured as the insured’s representative.

Public Adjuster

By signing this contract, I attest that my license, as issued by the Georgia Office of Insurance and Safety Fire Commission is valid and in full force and effect as of the date of signing this contract.

Notice of Right to Cancel: You, the insured, may cancel this contract at any time prior to midnight of the 3rd business day after the date of execution of this contract. Such rescission shall be in writing and mailed or  delivered to the public adjuster at the address stated in the contract within 3 business days. The rescission shall be deemed delivered or mailed if it is delivered by electronic transmittal to the email address or facsimile specified in the contract. If you exercise your right to cancel this contract, anything of value given by you under the contract will be returned to you within fifteen (15) business days following receipt of this notice. You will be liable for reasonable and necessary emergency out-of-pocket expenses or services which were paid or incurred by Southern Claim Adjusters LLC to protect the interests of the insured during the period preceding cancellation. To cancel this contract, mail, fax, or deliver in person a written notice indicating your intent to cancel and the date thereof to Southern Claim Adjusters LLC at: 237 Walden Pond Trail Senoia, Georgia 30276.

does hereby make, constitute and appoint Southern Claim Adjusters, LLC ("Attorney in Fact"), whose address is 237 Walden Pond Trail Senoia, Georgia 30276 to be its true and lawful attorney in fact irrevocably in its place and in its stead to: Endorse insurance proceeds checks made payable to Principal and possibly other parties so that those checks may be deposited to Southern Claim Adjusters, LLC. Client Funds Account (for checks that include any money owed to client) or Operating Account (for checks that are for public adjuster's fees and costs only). Any act, contract, agreement, writing or thing which shall be done, given, delivered, executed, or said by Southern Claim Adjusters, LLC., pursuant to this Power of Attorney for the purpose noted above shall be as good, valid, and effectual as if they had been done, given, delivered, executed, or said by Principal and Principal does hereby undertake and agree at all times to ratify, whatever its Attorney in Fact may lawfully do or cause to be done in or concerning the endorsement of insurance proceeds checks. Principal hereby authorizes its Attorney in Fact and Southern Claim Adjusters, LLC. to rely upon and act in accordance with this Power of Attorney and hereby indemnifies and holds harmless Attorney in Fact and Southern Claim Adjusters, LLC. in connection with any action that they may take in reliance or in connection with this Power of Attorney.