DEPARTMENT OF FINANCIAL SERVICES
Division of Consumer Services – Alternative Dispute Resolution Section
DFS-I0-510
Rev. 06/15
69J-176.022
Automobile Mediation Request Form
YOUR NAME:
Address:
Phone Number:
E-mail Address:
FULL NAME OF YOUR INSURANCE COMPANY:
Named Insured:
Address: (if different from above)
Phone Number: (if different from above)
Email Address: (if different from above)
Claim Number: Policy Number:
Is the Problem Related To: Property Damage Personal Injury (must be $10,000 or less)
Type of Dispute: Unsatisfactory Settlement Offer Other
BRIEF STATEMENT OF THE PROBLEM (including amount disputed): (Attach additional sheet if necessary)
You are entitled to mediation in accordance with s. 627.745, Florida Statutes, for any claim with bodily injury in an amount of $10,000 or less or any
claim for property damage in any amount, arising out of ownership, operation, use or maintenance of a motor vehicle before a lawsuit has been filed.
Your Dispute may qualify for mediation if:
The claim involves damages to property in any amount, or
The claim involves bodily injury damages in an amount of $10,000 or less, And
The claim has not been settled, And
No form or release has been signed with or for the insurance company, And
The claim is not involved in litigation.
Mediation Fee: The cost of mediation is $200 and shall be paid equally in the amount of $100 by the insured and the insurance company. The
mediation fee must be paid in the form of a certified check, money order or insurance company check made payable to the Department of Financial
Services. Participation in mediation is voluntary. Once the insurance company agrees to participate in mediation, you will be notified to submit the
mediation fee.
Complete this form and return it to:
Department of Financial Services
Division of Consumer Services
Alternative Dispute Resolution Section
200 E. Gaines Street
Tallahassee, Florida 32399-4212
Mediation@MyFloridaCFO.com
Fax 850-488-6372
