D
EPARTMENT OF FINANCIAL
S
ERVICES
Division of Consumer Services – Alternative Dispute Resolution Section
Request for Personal Residential Insurance Mediation
Name of Requestor: Request Submitted by: Insured Insurance Company
Name of Insured:
Address of Insured Property:
Phone Number: E-mail Address:
Mailing Address (if different):
IS THE INSURED REPRESENTED BY A PUBLIC ADJUSTER? Yes No
(if yes, please
rovide a copy of
he contrac
along with
his fo
)
Name:
Address:
Phone Number: E-mail Address:
IS THE INSURED 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: Email Address:
FULL NAME OF THE INSURANCE COMPANY:
Policy Number:
Claim Number:
Contact Person:
Phone Number: Email Address:
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)
The Residential Insurance Mediation Program, pursuant to 627.7015, Florida Statutes, is available to those insureds, as first-party claimants, or 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
Fax 850-488-6372
DFS-I0-2082
Rev. 06/18
69J-166.031
