Public Adjuster Form

Start your public adjuster authorization.

Complete the information below, review the contract pages, sign in the signature box, and submit it to Southern Claim Adjusters.

How It Works

One page. Fill, review, sign, submit.

The online fields collect the details needed to prepare the claim file. The original contract pages stay visible below so the authorization remains easy to review.

Begin Form Review Contract Email Claim Documents 470-215-9523

Online Authorization

Fill out the form and sign before submitting.

Required fields are marked by the browser as you go. Use your mouse, finger, or trackpad in the signature box.

Company Website

Policyholder Information Full Name(s) Phone Email Contractor Name Sales Rep Name Loss Address Primary Address if Different than Loss Address Date of Loss or Discovery Description of Loss

Insurance Carrier Information Insurance Carrier Policy Number Claim Number Public Adjuster Fee

Review & Acknowledge I have reviewed the public adjuster contract preview on this page. I authorize Southern Claim Adjusters LLC to communicate with the insurance carrier regarding this claim. I have reviewed the limited power of attorney page included in this contract preview.

Signature Insured's Printed Name Date

Insured Signature

Second Insured's Printed Name Date

Second Insured Signature

Contract Review

Start your public adjuster authorization.

One page. Fill, review, sign, submit.

Fill out the form and sign before submitting.

Review the full authorization before submitting.