D
EPARTMENT OF FINANCIAL
S
ERVICES
Division of Consumer Services – Alternative Dispute Resolution Section
Request for Commercial Residential Insurance Mediation
Name of Insured:
Are you a(n):
(Select one)
Homeowner’s Association Condominium Association
Cooperative Association Other Corporation
Address of Insured Property:
Name of Authorized Representative:
Phone Number: E-mail Address:
ARE YOU REPRESENTED BY A PUBLIC ADJUSTER? Yes No
(if yes, please provide a copy of the contract along with this form)
Name:
Address:
Phone Number: E-mail Address:
ARE YOU REPRESENTED BY AN ATTORNEY? Yes No
(if yes, please provide a copy of the letter of representation along with this form)
Name:
Address:
Phone Number: E-mail Address:
FULL NAME OF YOUR INSURANCE COMPANY:
Policy Number:
Claim Number:
Type of Dispute:
(check all that apply)
Unsatisfactory Settlement Offer Cause of Loss
Scope of Damages Scope of Repair
BRIEF STATEMENT OF THE PROBLEM (including amount disputed): (Attach additional sheet if necessary)
You are entitled to mediation pursuant to 627.7015, Florida Statutes, which sets forth a mediation procedure promoted by the critical need for effective,
fair, and timely, handling of personal residential property insurance claims for property insured by a personal residential insurance policy. The
Residential Insurance Mediation Program is available to those insureds, as first party claimants, and a third-party, as an assignee of the policy benefits,
who have personal residential claims resulting from damage to property located in Florida. The Residential Insurance Mediation Program does NOT
apply to commercial insurance, private passenger motor vehicle insurance, liability coverage in property insurance policies or National Flood Insurance
Program flood policies.
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
DFS-I1-1669
Rev.06/18
69J-166.002
