Your Full Name:* (First Middle & Last )
Your Vehicle's Year:* 
Date of Loss: 
At fault driver Insurance Company: 
At-fault driver policy number: 
Telephone Numbers:* (Very important)
E-mail Address:* 
Cost of Repairs: $: (Very important, please insert approximate Cost of Repairs) If known
Approximate Mileage at time of Accident  (If Known)
Your Amloss Claim Number: 
Primary Damage Area: 
At fault driver Name: 
Who was at fault?
(very important)
Was your vehicle a "Total Loss"?          
(very important)
Was your vehicle leased?     
Was vehicle repaired?     
Was vehicle in prior accident?     
Was there structural damage?     
Did you file your claim DIRECTLY with the OTHER DRIVER'S Insurance Company?      
Did airbag deploy?     
Do you still own vehicle?     
Were you or Anybody in your Vehicle hurt during the accident?     
How badly were you/they Hurt?:  
Are you represented by an Attorney for your injuries?     
To assist us in negotiating a favorable DV settlement for you, please describe your accident. * (Very important)
Also, feel free to leave any comments:


The undersigned vehicle owner (“Client”) hereby engages Amloss Claims & Arbitration, LLC (“Amloss”) to adjust the claim and distribute funds for/to the Client arising from the accident damage to the motor vehicle listed above, in relation to diminished value and loss of use. This agreement pertains to a non-emergency supplemental claim. Amloss is not a law firm and client may wish to consult an attorney regarding their claim. Fees and Notice of Assignment: The client agrees to pay and hereby assigns to Amloss thirty-five percent (35%) of the money recovered on behalf of client for diminished value and loss of use. Said assignment is absolute and for consideration. Client instructs insurance carrier to negotiate with Amloss and to disburse settlement proceeds directly to Amloss who will in turn deduct its fee and disburse funds to client within 5 business days. Client instructs Amloss to indorse any settlement checks on client’s behalf and negotiate same in Amloss’ account. Client has 3 days from the execution of this agreement to cancel this agreement without obligation by mailing cancellation to Amloss at the address listed below, certified mail, return receipt requested or other form of mailing which provides proof of delivery. This agreement is not binding upon either client or Amloss until signed by both Client and Public Adjuster and mailed or emailed to client. Pursuant to s. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive an 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 claim or repairs contains 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, Florida Statutes Pursuant to F.S. 626.8796 Client represents and warrants that all named insured have signed below..

By clicking the button below, I verify that all information provided above is correct,
I aver that I have authority to enter into this agreement, I consent to sign this application electronically, and I wish to submit this application for processing.

Melissa Ann Pollock public adjuster license number A1677245

1975 East Sunrise Blvd., Suite 800, Fort Lauderdale, FI 33304
Toll-Free: 855-806-4762
Phone: 954-652-1965
Fax: 954-337-0120
Licensed & Bonded with the Florida Department of Financial Services
Email: Missy@amloss.com

Thank you!

Please enter your Amloss claim number referenced on the NOTICE you received beginning with the letters "ADV" followed by a number.
Please enter your Amloss Claim Number here:  

IF YOU DO NOT HAVE A CLAIM NUMBER, please click the button below to proceed.

Click here to proceed
Espanol or Kreyòl Click Here