FEMA LOR

FEMA Letter Of Representation

Bulldog Adjuster
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FEMA
400 C Street SW, 3rd Floor SW
Washington, DC 20472-3010
Email: FEMA-FI-Appeals@fema.dhs.gov
Company Name
Submitting User
Submitting Email
Public Adjuster Email
Please forward all future correspondence and communications through Bulldog Adjusters INC. at the below listed address, emailand/or phone/fax numbers.

This representation assignment created hereby is absolute and unconditional. I hereby authorize my insurance company to directly deliver all correspondences and communications through Bulldog Adjusters INC. by email toClaims@bulldogadjusters.com or by mail to the office address listed below. I hereby grant Bulldog Adjusters INC. my full power of attorney to negotiate any insurance company claim regarding the above loss on my behalf and to negotiate and/or disburse funds.

Representative PA:
Bulldog Adjusters, INC.,
License # W825735
Phone # 877-737-7764
Email: Claims@bulldogadjusters.com
Business Address: 3127 W Hallandale Beach Blvd, Ste #102
Hallandale Beach, FL 33009

Policyholder's full name: {InsuredName}

Policyholder's current address: {LossAddress}

Policyholder's date and place of birth: {dateOf} {placeOf}

Name of third-party representative: Bulldog Adjusters

And a statement from the policyholder authorized the representative to act on their behalf and for the insurer to release records to the representative:

To whom it may concern,

I expressly grant permission to FEMA to release my records to this third-party representative

In the county of {CountyOf}

The policyholders' signatures must be submitted with the following statement prescribed by 28 U.S.C. 1746.

I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on {executedOn}.

"Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured,prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of aclaim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, ormisleading information concerning any fact or thing material to the claim commits a felony of the third degree, punishable asprovided in s. 775.082, 1s. 775.083, or s. 775.084, Florida Statutes."
Policy Number*
Claim Number*
Cause of Loss*
Date of Loss*

MonthDayYear
Date
Insured Name*
Additional Insured Name
leave blank if none
Date of Birth:*

MonthDayYear
Date
Place of Birth:*
Additional Insured - Date of Birth:

MonthDayYear
Date
Additional Insured - Place of Birth:
Email*
example@example.com
Loss Address*
City, State and Zip Code MUST be Provided
Insurance Company*
Authorized Representative:*
County of:*
Executed on Date*

MonthDayYear
Date
Executed on Day
Please type #
Executed on Month
Please type out month name, for example, October, November, December.
Executed on Year
Insured*
Insured Signature*
Date*

MonthDayYear
Date
Additional Insured (Leave Blank if None)
Additional Insured Signature
Date

MonthDayYear
Date
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SessionId
Should be Empty:

FEMA Letter Of Representation