4600 Sheridan Street, Suite 303, Hollywood, FL 33021
Call us at (954)284-0900

"We Help You When Your Insurance Company Won't"

Welcome to Florida Professional Law Group, PLLC. We look forward to being able to review your insurance claim to see if we may be able to help you.

Please complete the information below and then electronically sign the 6 documents that are part of our retainer package.

* If you don't know any of the information requested, please leave the field blank.

Client #1 (Required)

First Name
Last Name
Last 4 digits of
Social Security #
XXX-XX-
Preferred Name
Phone Number
Cell Phone
Email
Gender
   
Client #1 Physical Address
Address
City
State
Zip
   
Client #1 Mailing Address
Same as above
Address
City
State
Zip
   

Client #2

First Name
Last Name
Preferred Name
Last 4 digits of
Social Security #
XXX-XX-
Phone Number
Cell Phone
Email
   

Client #2 Physical Address

Same as above
Address
City
State
Zip
   

Client #2 Mailing Address

Same as above
Address
City
State
Zip
   

Client #3

First Name
Last Name
Preferred Name
Last 4 digits of
Social Security #
XXX-XX-
Phone Number
Cell Phone
Email
   

Client #3 Physical Address

Same as above
Address
City
State
Zip
   

Client #3 Mailing Address

Same as above
Address
City
State
Zip
   

Claim Details

Date of Loss mm/dd/yyyy
Property Address
Property City
Property State
Property Zip
Description of Loss
Policy Number
Claim Number
   
   

Insurance Agent

Insurance Agent Name
Address
City
State
Zip
Fax
   

Insurance Company

Insurance Company Name
Address
City
State
Zip
Fax
   

First Mortgage

Mortgage Payments:
Are the people listed on the insurance policy as "Named Insureds" the same people that signed the mortgage?
Received Foreclosure Notice:
Mortgage Company
Address
City
State
Zip
Fax
Loan Number
   

Second Mortgage

Mortgage Payments:
Are the people listed on the insurance policy as "Named Insureds" the same people that signed the mortgage?
Received Foreclosure Notice:
Mortgage Company
Address
City
State
Zip
Fax
Loan Number

Public Adjustor

If you are working with a public adjuster please complete as much of the following as possible.
Public Adjuster Company
First Name
Last Name
Phone
Fax
Email