English Agreement Client Information* Denotes required fieldsClient Name*Email Address* Phone Number*Mobile*Insurance Company*Policy Number*Claim Details* Denotes required fieldsProperty Address*City*State*Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code*Cause of Loss*Date of Loss* Damaged Areas*Have you received Payment for your Claim ?*YesNoUpload a copy of the payment Drop files here or Claim Number if ApplicableHas your claim already been Denied?*YesNoUpload the copy of denial documents Drop files here or Would you like to submit any additional losses?*NoYesClaims Details 2Cause of Loss*Date of Loss* Damaged Areas*Have you received Payment for your Claim ?*YesNoUpload a copy of the payment Drop files here or Claim Number if ApplicableHas your claim already been Denied?*YesNoUpload the copy of denial documents Drop files here or If you have hired an Appraiser or Public Adjuster please enter his name, otherwise enter NONE*Is there additional insured name ?*NoYesPrint your name*Print your name (2nd)*Date* Date (2nd)* Signature*Signature (2nd)*English Contingency Agreement Statement of Client's RightsTerms and Conditions* By checking this box you affirm that you have thoroughly read and understood the terms and conditions of retainer agreement provided herein. You understand you are hiring legal counsel for this matter and you further understand you are free to hire any attorney of your choosing, but have chosen to retain TABARES LAW, P.A., and you are doing so freely, knowingly, and intelligently. Moreover, you have done so after speaking to an attorney with the firm. Read and understood* By checking this box you affirm you have read and understand the following: PURSUANT TO FLORIDA STATUTES SECTION 817.234, ANY PERSON WHO, WITH 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 A CLAIM UNDER AN INSURANCE POLICY KNOWING THAT THE PROOF OF LOSS OR ESTIMATE OF COST OR REPAIRS CONTAINS ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION CONCERNING ANY FACT OR THING MATERIAL TO THE CLAIM, COMMITS A FELONY OF THE THIRD DEGREE PUNISHABLE AS PROVIDED IN S. 775.082, S. 775.083, or S. 775.084 OF THE FLORIDA STATUTES. This iframe contains the logic required to handle Ajax powered Gravity Forms.
