Harshbarger Enterprises
Public Insurance Adjuster Contract
Full Name(s)
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Loss Address (Type Street Address, City, and Zip Code
*
Primary Address if Different than Loss Address
Date of Loss or Discovery
*
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Month
-
Day
Year
Date
Description of Loss (Wind/Hail, Fire, Water, etc...)
*
Insurance Information
Insurance Carrier(s) Name
*
Policy Number
*
Claim Number/ Roofing Company
Insured:
By signing this agreement, the insured hereby authorizes Harshbarger Enterprises LLC to initiate and maintain communication with the insurer and its representatives on behalf of the insured as the insured's representative
First Named Insured's Printed Name
*
First Named Insured's Signature
*
Date
*
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Month
-
Day
Year
Date
Second Named Insured's Printed Name (if applicable)
Second Named Insured's Signature (if applicable)
Date
-
Month
-
Day
Year
Date
Limited Power of Attorney
I (the "Principal") hereby make, constitute, and appoint Harshbarger Enterprises LLC. to be my true and lawful "Attorney in Fact"
Principal's Full Name
*
Prinicpal's Printed Name (Print)
*
Date
*
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Month
-
Day
Year
Date
Principals Signature
*
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