Filing Number: 790965
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| Filing Accepted: 11/8/2024 |
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| Street Address
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4305 SHIRLEY AVE. |
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JACKSONVILLE,
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32210
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WITHHELD |
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Insured |
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| Last/Business Name* |
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COX |
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First Name |
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STERLING |
| Policy # * |
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FLP71186 |
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Claim #* |
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1390677-241013 |
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Attorney is Applicable
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| Last Name* |
LONG
First Name *
JESSE
Initial
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1499 W PALMETTO PARK RD. STE. 216 |
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BOCA RATON
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FL
33486
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JESSE@LEGAL-GRIT.COM |
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| Insurer Type
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 Authorized Insurer
 Unauthorized Insurer
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| Insurer Name |
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| Insurer Name* |
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ASI PREFERRED INSURANCE CORP.
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NAIC Company Code 13142 |
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| Name of individual responsible for violation (if any):*
ANY AND ALL ADJUSTERS, SUPERVISORS, MANAGEMENT, ATTORNEYS AND INDIVIDUALS ASSOCIATED WITH OR RETAINED BY ASI PREFERRED INSURANCE CORP., INVOLVED WITH THE HANDLING OF THIS CLAIM INCLUDING BUT NOT LIMITED TO THE FOLLOWING: ASI PREFERRED INSURANCE CORP.
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| Type of Insurance
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Residential Property & Casualty
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| Reason for Notice
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Claim Delay
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Unsatisfactory Settlement Offer
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Unfair Trade Practice
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Other
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Violation of Adjusters’ Ethical Requirements; not adjusting claims and evaluating the loss properly,
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Statutory provision(s) which the insurer allegedly violated.
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| 624.155(1)(b)(1) |
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Not attempting in good faith to settle claims when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for her or his interests.
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| 624.155(1)(b)(3) |
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Except as to liability coverages, failing to promptly settle claims, when the obligation to settle a claim has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.
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| 626.9541(1)(i)(2) |
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A material misrepresentation made to an insured or any other person having an interest in the proceeds payable under such contract or policy, for the purpose and with the intent of effecting settlement of such claims, loss, or damage under such contract or policy on less favorable terms than those provided in, and contemplated by, such contract or policy.
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| 626.9541(1)(i)(3)(a) |
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Failing to adopt and implement standards for the proper investigation of claims.
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| 626.9541(1)(i)(3)(b) |
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Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
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| 626.9541(1)(i)(3)(c) |
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Failing to acknowledge and act promptly upon communications with respect to claims.
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| 626.9541(1)(i)(3)(d) |
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Denying claims without conducting reasonable investigations based upon available information.
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| 626.9541(1)(i)(3)(e) |
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Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
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| 626.9541(1)(i)(3)(f) |
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Failing to promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement.
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| 626.9541(1)(i)(3)(g) |
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Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
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| 626.9541(1)(i)(3)(h) |
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Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
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| 626.9541(1)(o)(1) |
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Knowingly collecting any sum as a premium or charge for insurance, which is not then provided, or is not in due course to be provided, subject to acceptance of the risk by the insurer, by an insurance policy issued by an insurer as permitted by this code.
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| 626.9541(1)(i)(4) |
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Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 60 days after an insurer receives notice of a residential property insurance claim, determines the amounts of partial or full benefits, and agrees to coverage, unless payment of the undisputed benefits is prevented by factors beyond the control of the insurer as defined in s. 627.70131(5).
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| 626.9541(1)(i)(3)(j) |
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Altering or amending an insurance adjuster’s report without:
(I) Providing a detailed explanation as to why any change that has the effect of reducing the estimate of the loss was made; and
(II) Including on the report or as an addendum to the report a detailed list of all changes made to the report and the identity of the person who ordered each change; or
(III) Retaining all versions of the report, and including within each such version, for each change made within such version of the report, the identity of each person who made or ordered such change;
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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
FLORIDA STATUTES VIOLATED (continued)
§627.70131(1)(a) - Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 7 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer’s claim file and dated. A communication made to or by a representative of an insurer with respect to a claim shall constitute communication to or by the insurer.
§627.70131(2) - Such acknowledgment must be responsive to the communication. If the communication constitutes a notification of a claim, unless the acknowledgment reasonably advises the claimant that the claim appears not to be covered by the insurer, the acknowledgment must provide necessary claim forms, and instructions, including an appropriate telephone number.
§627.70131(3)(a) - Unless otherwise provided by the policy of insurance or by law, within 7 days after an insurer receives proof-of-loss statements, the insurer shall begin such investigation as is reasonably necessary unless the failure to begin such investigation is caused by factors beyond the control of the insurer.
§627.70131(3)(b) - If such investigation involves a physical inspection of the property, the licensed adjuster assigned by the insurer must provide the policyholder with a printed or electronic document containing his or her name and state adjuster license number. An insurer must conduct any such physical inspection within 30 days after its receipt of the proof-of-loss statements.
§627.70131(3)(c) - Any subsequent communication with the policyholder regarding the claim must also include the name and license number of the adjuster communicating about the claim. Communication of the adjuster’s name and license number may be included with other information provided to the policyholder.
§627.70131(3)(e) - The insurer must send the policyholder a copy of any detailed estimate of the amount of the loss within 7 days after the estimate is generated by an insurer’s adjuster. This paragraph does not require that an insurer create a detailed estimate of the amount of the loss if such estimate is not reasonably necessary as part of the claim investigation.
§627.70131(7)(a) - Within 60 days after an insurer receives notice of an initial, reopened, or supplemental property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay is caused by factors beyond the control of the insurer. The insurer shall provide a reasonable explanation in writing to the policyholder of the basis in the insurance policy, in relation to the facts or applicable law, for the payment, denial, or partial denial of a claim. If the insurer’s claim payment is less than specified in any insurer’s detailed estimate of the amount of the loss, the insurer must provide a reasonable explanation in writing of the difference to the policyholder. Any payment of an initial or supplemental claim or portion of such claim made 60 days after the insurer receives notice of the claim, or made after the expiration of any additional timeframe provided to pay or deny a claim or a portion of a claim made pursuant to an order of the office finding factors beyond the control of the insurer, whichever is later, bears interest at the rate set forth in s. 55.03. Interest begins to accrue from the date the insurer receives notice of the claim. The provisions of this subsection may not be waived, voided, or nullified by the terms of the insurance policy. If there is a right to prejudgment interest, the insured must select whether to receive prejudgment interest or interest under this subsection. Interest is payable when the claim or portion of the claim is paid. Failure to comply with this subsection constitutes a violation of this code. However, failure to comply with this subsection does not form the sole basis for a private cause of action.
RELEVANT POLICY LANGUAGE
ASI Preferred Insurance Corp. (the “Insurance Company”) issued policy of insurance number FLP71186 (the “Policy”) to Sterling S. Cox (the “Insured”) for the property located at 4305 Shirley Ave., Jacksonville, FL 32210 (the “Property”). The Policy covers all risks unless expressly excluded or limited. On or about 7/23/2024, the Property sustained direct physical and resultant damage as the result of a sudden and accidental windstorm and/or fallen tree. Although the Policy provides coverage for all the losses, damages, and expenses the Insured suffered and incurred, the Insurance Company has failed and refused to compensate the Insured for all damage sustained to the Property as well as his contents and additional living expenses. The specific policy language at issue includes, but may not be limited to, the Insurance Company’s express obligation to insure against risk of direct loss to property described in Coverages A, B, C, D and any Additional Coverages. To the best of the Insured’s information and belief, specific policy language that is known and relevant to the violations referenced herein includes, but is not limited to the following:
See Subject Policy number FLP71186.
SECTION I – PROPERTY COVERAGES
COVERAGE A - Dwelling
We cover:
1. The dwelling on the "residence premises" shown
in the Declarations, including structures attached to the dwelling; and
2. Materials and supplies located on or next to the "residence premises" used to construct, alter or repair the dwelling or other structures on the "residence premises."
This coverage does not apply to land, including land on which the dwelling is located.
This coverage does not apply to land, including land on which the dwelling is located.
COVERAGE B – Other Structures
We cover other structures on the "residence premises" set apart from the dwelling by clear space. This includes structures connected to the dwelling by only a fence, utility line, or similar connection.
This coverage does not apply to land, including land on which the other structures are located.
We do not cover other structures:
1. Used in whole or in part for "business"; or
2. Rented or held for rental to any person not a tenant of the dwelling, unless used solely as a private garage.
The limit of liability for this coverage will not be more than 10% of the limit of liability that applies to Coverage A. Use of this coverage does not reduce the Coverage A limit of liability.
COVERAGE C – Personal Property
We cover personal property owned or used by an "insured" while it is anywhere in the world. At your request, we will cover personal property owned by:
1. Others while the property is on the part of the "residence premises" occupied by an "insured";
2. A guest or a "residence employee," while the property is in any residence occupied by an "insured."
Our limit of liability for personal property usually lo-cated at an "insured's" residence, other than the "resi-dence premises," is 10% of the limit of liability for Coverage C, or $1000, whichever is greater. Personal property in a newly acquired principal residence is not subject to this limitation for the 30 days from the time you begin to move the property there.
[***]
COVERAGE D - Loss Of Use
The limit of liability for Coverage D is the total limit for all the coverages that follow.
1. If a loss covered under this Section makes that part of the "residence premises" where you reside not fit to live in, we cover, at your choice, either of the following. However, if the "residence premises" is not your principal place of residence, we will not provide the option under paragraph b. below.
a. Additi onal Living Expense, meaning any necessary increase in living expenses Incurred by you so that your household can maintain its normal standard of living; or
b. Fair Rental Val ue, meaning the fair rental value of that part of the "residence premises" where you reside less any expenses that do not continue while the premises is not fit to live in.
Payment under a. or b. will be for the shortest time required to repair or replace the damage or, if you permanently relocate, the shortest time required for your household to settle elsewhere.
[***]
ADDITIONAL COVERAGES
1. Debris Removal. We will pay your reasonable expense for the removal of:
a. Debris of covered property if a Peril Insured Against that applies to the damaged property causes the loss; or
b. Ash, dust or particles from a volcanic eruption that has caused direct loss to a building or property contained in a building.
This expense is included in the limit of liability that applies to the damaged property. If the amount to be paid for the actual damage to the property plus the debris removal expense is more than the limit of liability for the damaged property, an additional 5% of that limit of liability is available for debris removal expense.
We will also pay your reasonable expense, up to $500, for the removal from the "residence premises" of:
a. Your tree(s) felled by the peril of Windstorm or Hail;
b. Your tree(s) felled by the peril of Weight of Ice, Snow or Sleet; or
c. A neighbor's tree(s) felled by a Peril Insured Against under Coverage C;
provided the tree(s) damages a covered structure. The $500 limit is the most we will pay in any one loss regardless of the number of fallen trees.
2. Reasonable Repairs. In the event that the covered property is damaged by an applicable Peril Insured Against, we will pay the reasonable cost incurred by you for necessary measures taken solely to protect against further damage. If the measures taken involve repair to other damaged property, we will pay for those measures only if that property is covered under this policy and the damage to that property is caused by an applicable Peril Insured Against.
This coverage:
a. Does not increase the limit of liability that applies to the covered property;
b. Does not relieve you of your duties, in case of
a loss to covered property, as set forth in SECTION I - CONDITION 2.d.
[***]
9. Glass or Safety Glazing Material.
We cover:
a. The breakage of glass or safety glazing mate-rial which is part of a covered building, storm door or storm window; and
b. Damage to covered property by glass or safety glazing material which is part of a building, storm door or storm window.
This coverage does not include loss on the "resi-dence premises" if the dwelling has been vacant for more than 30 consecutive days immediately before the loss. A dwelling being constructed is not considered vacant.
Loss for damage to glass will be settled on the ba-sis of replacement with safety glazing materials when required by ordinance or law.
This coverage does not increase the limit of liabil-ity that applies to the damaged property.
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SECTION I – PERILS INSURED AGAINST
COVERAGE A - DWELLING and COVERAGE B -
OTHER STRUCTURES
We insure against risk of direct loss to property described in Coverages A and B only if that loss is a physical loss to property. We do not Insure, however, for loss:
[***]
3. Excluded under Section I – Exclusions.
Under items 1. and 2., any ensuing loss to property described in Coverages A and B not excluded or excepted in this policy is covered.
COVERAGE C - PERSONAL PROPERTY
We insure for direct physical loss to the property described in Coverage C caused by a peril listed below unless the loss is excluded in SECTION I -EXCLUSIONS.
[***]
2. Windstorm or hail.
This peril does not include loss to the property contained in a building caused by rain, snow, sleet, sand or dust unless the direct force of wind or hail damages the building causing an opening in a roof or wall and the rain, snow, sleet, sand or dust enters through this opening.
This peril includes loss to watercraft and their trailers, furnishings, equipment, and outboard en-gines or motors, only while inside a fully enclosed building.
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10. Falling objects.
This peril does not include loss to property contained in a building unless the roof or an outside wall of the building is first damaged by a falling object. Damage to the falling object itself is not included.
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SECTION I – CONDITIONS
1. Insurable Interest and Limit of Liability. Even if more than one person has an insurable interest in the property covered, we will not be liable in any one loss:
a. To the "insured" for more than the amount of the "insured's" interest at the time of loss; or
b. For more than the applicable limit of liability.
2. Your Duties After Loss. In case of a loss to covered property, you must see that the following are done:
a. Give prompt notice to us or our agent;
b. Notify the police in case of loss by theft;
c. Notify the credit card or fund transfer card company in case of loss under Credit Card or Fund Transfer Card coverage;
d. Protect the property from further damage. If repairs to the property are required, you must:
(1) Make reasonable and necessary repairs to protect the property; and
(2) Keep an accurate record of repair expenses;
e. Prepare an inventory of damaged personal
property showing the quantity, description, actual cash value and amount of loss. Attach all bills, receipts and related documents that justify the figures in the inventory;
f. As often as we reasonably require:
(1) Show the damaged property;
(2) Provide us with records and documents we request and permit us to make copies; and
(3) Submit to examination under oath, while not in the presence of any other "insured," and sign the same;g. Send to us, within 60 days after our request, your signed, sworn proof of loss which sets forth, to the best of your knowledge and belief:
3. Loss Settlement. Covered property losses are settled as follows:
a. Property of the following types:
(1) Personal property;
(2) Awnings, carpeting, household appliances, outdoor antennas and outdoor equipment, whether or not attached to buildings; and
(3) Structures that are not buildings; at actual cash value at the time of loss but not more than the amount required to repair or replace.
b. Buildings under Coverage A or B at replacement cost without deduction for depreciation, subject to the following:
(1) If, at the time of loss, the amount of insurance in this policy on the damaged building is 80% or more of the full replacement cost of the building immediately before the loss, we will pay the cost to repair or replace, after application of deductible and without deduction for depreciation, but not more than the least of the following amounts:
(a) The limit of liability under this policy that applies to the building;
(b) The replacement cost of that part of the building damaged for like construction and use on the same premises; or(1) The time and cause of loss;
(2) The interest of the "insured" and all others in the property involved and all liens on the property;
(3) Other Insurance which may cover the loss;
(4) Changes in title or occupancy of the property during the term of the policy;
(5) Specifications of damaged buildings and detailed repair estimates;
(6) The inventory of damaged personal property described in 2.e. above;
(7) Receipts for additional living expenses incurred and records that support the fair rental value loss; and
(8) Evidence or affidavit that supports a claim under the Credit Card, Fund Transfer Card, Forgery and Counterfeit Money coverage, stating the amount and cause of loss.(c) The necessary amount actually spent to repair or replace the damaged building.
(2) If, at the time of loss, the amount of insurance in this policy on the damaged building is less than 80% of the full replacement cost of the building immediately before the loss, we will pay the greater of the following amounts, but not more than the limit of liability under this policy that applies to the building:
(a) The actual cash value of that part of the building damaged; or
(b) That proportion of the cost to repair or replace, after application of deductible and without deduction for depreciation, that part of the building damaged, which the total amount of insurance in this policy on the damaged building bears to 80% of the replacement cost of the building.
(3) To determine the amount of insurance required to equal 80% of the full replacement cost of the building immediately before the loss, do not include the value of:
(a) Excavations, foundations, piers or any supports which are below the undersurface of the lowest basement floor;
(b) Those supports in (a) above which are below the surface of the ground inside the foundation walls, if there is no basement; and
(c) Underground flues, pipes, wiring and drains.
(4) We will pay no more than the actual cash value of the damage until actual repair or replacement is complete. Once actual repair or replacement is complete, we will settle the loss according to the provisions of b.(1) and b.(2) above.
However, if the cost to repair or replace the damage is both:
(a) Less than 5% of the amount of insurance in this policy on the building; and
(b) Less than $2500;
we will settle the loss according to the provisions of b.(1) and b.(2) above whether or not actual repair or replacement is complete.
(5) You may disregard the replacement cost loss settlement provisions and make claim under this policy for loss or damage to buildings on an actual cash value basis.
You may then make claim within 180 days after loss for any additional liability according to the provisions of this Condition 3. Loss Settlement
[***]
6. Appraisal. If you and we fail to agree on the amount of loss, either may demand an appraisal of the loss. In this event, each party will choose a competent appraiser within 20 days after receiving a written request from the other. The two appraisers will choose an umpire. If they cannot agree upon an umpire within 15 days, you or we may request that the choice be made by a judge of a court of record in the state where the "residence premises" is located . The appraisers will separately set the amount of loss. If the appraisers submit a written report of an agreement to us, the amount agreed upon will be the amount of loss. If they fail to agree, they will submit their differences to the umpire. A decision agreed to by any two will set the amount of loss.
Each party will:
a. Pay its own appraiser; and
b. Bear the other expenses of the appraisal and umpire equally.
7. Other Insurance.If a loss covered by this policy is also covered by other insurance, we will pay only the proportion of the loss that the limit of liability that applies under this policy bears to the total amount of insurance covering the loss.
8. Suit Against Us. No action can be brought unless the policy provisions have been complied with and the action is started within one year after the date of loss.
[***]
10. Loss Payment. We will adjust all losses with you.
We will pay you unless some other person is named in the policy or is legally entitled to receive payment. Loss will be payable 60 days after we receive your proof of loss and:
a. Reach an agreement with you;
b. There is an entry of a final judgment; or
c. There is a filing of an appraisal award with us.
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Coverage A – Dwelling
Coverage B – Other Structures
Coverage C – Personal Property
Personal Property Replacement Cost
Law and Ordinance
Mold/Fungi
Building Code Effectiveness Grading Schedule
All Optional Coverage provisions
All Additional Coverage provisions
All Coverage(s) provided by Endorsement or Rider
The Declarations Page
Loss Payment or Settlement provision
Duties in Event of Loss Policy provision
The insurance policy's definition section
The insurance policy's exclusion of coverage provisions
All insurance policy provisions that provide coverage to the property
All policy provisions.
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Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
Form DFS-10-363, Rev. 10/14/2008, contains a field for the Insured to include their email address(es). Prior to filing the CRN, said form contains an instruction that, in the event the insureds do not with for certain information to become part of the public record, the insureds must simply include the term “WITHHELD” to satisfy the filing requirement. This is further established through the following statement with appears on Civil Remedy Notices which have been filed:
NOTE: Information submitted as part of this civil remedy notice is public record. Data entered into this form will be displayed on the DFS website for public review. Please DO NOT enter Social Security Numbers, personal medical information, personal financial information or any other confidential or private information you do not want available for public review.
As any information contained herein becomes part of the public record, the Insured has withheld their email addresses so as not to make same available for public review and indicated same accordingly. Furthermore, as the insureds are represented by counsel, it would be improper for any representative of ASI Preferred Insurance Corp. to contact the Insured directly for any reason utilizing their email addresses and, as such, the information is neither material to ASI Preferred Insurance Corp.’s ability to correct the violations contained herein nor required by the Department of Financial Services. ASI Preferred Insurance Corp. should direct all follow-up correspondences to the attorney listed above.
Furthermore, Form DFS-10-363, Rev. 10/14/2008, in the above section requesting people with knowledge as to the allegations in the instant CRN gets cut off, the following are those responsible for the violations alleged herein:
Furthermore, while Form DFS-10-363, Rev. 10/14/2008, does not provide a place for the address of the insurer to be input, the following are the addresses provided by ASI Preferred Insurance Corp. to the Florida Office of Insurance Regulation: ADMINISTRATIVE 1 ASI Way, St. Petersburg, Florida 33702-2514; HOME 1 ASI Way, St. Petersburg, Florida 33702-2514 MAILING 1 ASI Way, St. Petersburg, Florida 33702-2514 LOCATION OF RECORDS 1 ASI Way, St. Petersburg, Florida 33702-2514. Finally, as the above section requesting people with knowledge as to the allegations in the instant CRN often gets cut off, the following are those responsible for the violations alleged herein: ANY AND ALL ADJUSTERS, SUPERVISORS, MANAGEMENT, ATTORNEYS AND INDIVIDUALS ASSOCIATED WITH OR RETAINED BY ASI PREFERRED INSURANCE CORP., INVOLVED WITH THE HANDLING OF THIS CLAIM INCLUDING BUT NOT LIMITED TO THE FOLLOWING: ASI PREFERRED INSURANCE CORP.’S HEAD GENERAL COUNSEL; MATTHEW BARKER (FL LICENSE #W200084)- SR. PROPERTY COMPLEX ADJUSTER; KATHRYN DEAN, SR COMPLEX CLAIMS ADJUSTER - INSIDE FL LICENSE # W440279; NATHAN GIBSON – FIELD ADJUSTER;DAVID LAWMAN-FIELD ADJUSTER, RYZE CLAIMS SOLUTIONS; AND ANY ADDITIONAL REPRESENTATIVES FROM PROGRESSIVE AND/OR ASI PREFERRED INSURANCE CORP. INVOLVED IN THE ADJUSTMENT/INVESTIGATION OF THE CLAIM.
FACTS:
1) Failure to pay claim in full;
2) Failure to property investigate claim;
3) Failure to act in due diligence and good faith to resolve claim;
4) Placing financial interest of insurer before that of policy holders and claimants;
5) Failure to properly train, evaluate and manage adjusters;
6) Looking for ways to deny coverage, pay less, delay payment and otherwise “low ball” or “stone wall” claim;
7) The reasons for this may be attributed to improper training, supervision, and/or motivation of adjusters and claim supervisors to promptly and fairly investigate, adjust and pay full benefits available to all beneficiaries. The insurer may have failed to adopt proper standards of investigation and adjustment of losses or is otherwise not implementing those standards because full payment and prompt payment for the loss is not occurring.
In Florida, the work of adjusting insurance claims engages the Public Trust. ASI PREFERRED INSURANCE CORP. (“Insurance Company”) has breached this duty by its improper adjustment of its Insured’s claim of loss. The Insurance Company’s handling and adjustment of its Insured’s claim of loss and the conduct of the adjusters, supervisors, management and individuals associated with or retained by the Insurance Company in this claim to date evidences that the Insurance Company has failed to create and implement adequate guidelines for the proper investigation to evaluate claims handling and for training and supervision of employees resulting in statutory violations set forth above. The Insurance Company has also failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the Insured’s insurance claim for damages. To date, notwithstanding the Insured’s pleas for assistance, The Insurance Company has refused to pay the full amount of its Insured’s claim.
The following facts shall serve to outline the unreasonable delays, complete lack of claims handling by the Insurance Company resulting in no substantive investigation of the Insured’s claim and no claim payment of the Insured’s claim to date, evidencing the Insurance Company’s pattern and practice of placing its own financial interests above that of its Insureds.
ASI Preferred Insurance Corp. (the “Insurance Company”) issued policy of insurance number FLP71186 (the “Policy”) to Sterling S. Cox (the “Insured”) for the property located at 4305 Shirley Ave., Jacksonville, FL 32210 (the “Property”). The Policy covers all risks unless expressly excluded or limited.
On or about 7/23/2024, the Property sustained damages as a result of a direct physical loss and resultant ensuing from a sudden and accidental windstorm and/or a fallen tree. The Property sustained damage to the following areas including but not limited to the Exterior: Awning, Masonry-Brick Veneer, Framing (including Roof Trusses), Shingle Roofing System, Flat Roofing System, Gutters; Interior: Kitchen, Dining Room, Living Room, Hallway, Bedroom 1, Bedroom 2, Bedroom 3 during a covered peril insured against under the subject Policy. After becoming aware of the substantial damage to the Property, the Insured’s promptly reported the damage to the Insurance Company on 7/23/2024. Thereafter, the Insurance Company acknowledged the claim and assigned claim number 1390677-241013 (the “Claim”). Following the Insured’s timely reporting of the Claim, the Insurance Company assigned adjustment of the claim to Matthew Barker, FL Lic.#W200084,SR. Property Complex Adjuster, who is believed to have enlisted the assistance of David Lawman, a field adjuster from Ryze Claims Solutions, to perform an inspection of the Subject Property.
After timely reporting the Loss to ASI, the Insured timely mitigated his damages by contacting Alive Builders to install an emergency roof tarp over the portion of the Property impacted by the fallen tree. The Insured incurred $1,100.00 for the aforementioned emergency mitigation services. Additionally, the Insured hired SouthernPro Tree Co. for emergency removal of the large fallen live Oak tree. A Crane was required for limbs and debris removal from the home and cars. SouthernPro Tree Co. hauled and removed the tree and damaged building debris for a total of $12,500.00. Lastly, due to the age of the Property, the Insured was required to hire a professional to test for Asbestos. As such, the Insured incurred $190.00 for said services and fortunately, the test came back negative and no Asbestos removal was needed as a result of the subject Loss. While the emergency service professionals worked diligently to mitigate the Insured’s damages throughout the Property, the Insured provided documentation to ASI for the incurred out of pocket costs for same as required under the Policy. Notwithstanding, the Insurance Company has refused to honor its contractual obligation to issue payment for these reasonable and necessary services. Despite providing the Insurance Company with all relevant information including the contact information for all involved with the emergency mitigation services, and/or necessary repairs, the Insurance Company failed to respond to the Insured’s correspondence or their request for cooperation to assist in mitigating their damages and restoring the Property. The failure to promptly communicate is a violation of 626.9541(1)(i)3(c) and the subject Policy.
On or about 7/26/2024, David Lawman completed an inspection of the subject Property on behalf of the Insurance Company. It was clear from the inspection that David Lawman was not either inexperienced and/or was disinterested in gaining relevant information supporting coverage under the Policy from the Insured. Further, it was evident throughout the inspection that the field adjuster was merely going through the perfunctory motions of the inspection without regard to detail. This can also be confirmed based on the estimate that was provided to ASI from Mr. Lawman that totaled only $15,235.26 and did not account for the replacement of the damaged shingle and flat roofing systems, nor any damages for the structural damage to the Property, nor the most obvious for the removal of the fallen tree and ensuing interior damages at the subject Property, despite clear evidence of damages warranting at or around a total loss of the subject Property.
On 7/27/2024, the Insured retained the services of public adjusters, Krista Norton and Brian Ragin of Gold Star Adjusters, Inc. to assist with the adjustment of the claim and to provide the Insured with the expertise needed to properly assess the extent of damages at the Property and obtain the full amount of insurance benefits owed under the Policy to return the Insured to pre-loss condition. On 7/27/2024 Brian Ragin & Krista Norton of Gold Star Adjusters emailed the Insurance Company a copy of their Letter of Representation which set forth the following:
"To whom it may concern,
Please find attached our contract of representation for this policyholder. If this claim is currently closed, please consider this letter and the attached contract a formal written request to re-open the claim.
Please forward promptly a true copy of the insurance policy, including declarations page, as well as any estimates, reports (engineer, contractor, adjuster, etc.), and a copy of any correspondence provided to the policyholder, or received from the policyholder.
Please be advised that the policyholder(s) intend(s) to receive RCV, Ordinance and Law and any other rights he/she/they have under this policy for this claim/loss.
If a check is issued as a result of this claim, please include “Gold Star Adjusters” as a payee, and send any checks to 3771 San Jose Place, Suite 24, Jacksonville, FL 32257, as indicated by the policyholder in the attached agreement in order to avoid additional delays.
Please also provide the name and contact information for a claim representative or have a representative contact me to discuss and/or inspect damages. Please immediately notify Gold Star Adjusters if there are any post loss obligations of the insured that need to be completed or provided to you."
The Insured’s public adjusters inspected the Property, provided a comprehensive Xactimate repair/damage estimate, assisted the Insured in retaining various consultants/professionals to assess the cause and amount of damages and mitigation efforts needed. Following the Inspection of the Loss, the Insured’s public adjusters produced a comprehensive Xactimate repair estimate totaling $217231.81, that included but was not limited to: repairs to the Exterior: Awning, Masonry-Brick Veneer, Framing (including Roof Trusses), Shingle Roofing System, Flat Roofing System, Gutters; Interior: Kitchen, Dining Room, Living Room, Hallway, Bedroom 1, Bedroom 2, Bedroom 3 to restore these areas back to pre-loss condition, as well as incurred costs for the aforementioned emergency repairs/mitigation efforts other line items for general conditions, debris removal and other reasonable and necessary costs.
On July 29, 2024 Mathew Barker (FL License #W200084), Sr. Property Complex Adjuster contacted Mr. Ragin via telephone advising he was going to send over the Certified Copy of the Policy and the additional claim documentation Gold Star requested in its Letter of Representation. When Gold Star did not receive the documents or any correspondence from Mr. Barker, Ms. Norton on August 14, 2024 sent the following email to ASI:
To whom it may concern,
We submitted our Letter of Representation, Contract and requested a true
copy of the insurance policy, including declarations page, and any other
claim related documents and letters via email at 3:08PM on July 27th, 2024, with no response via email or USPS, it?s now August 14, 2024.
On July 29th, 2024, Matthew from Progressive / ASI PREFERRED INSURANCE CORP reached out to Brian Ragin (The other Public Adjuster on file) via phone and told Brian he would be sending an email over requesting information and providing the information we requested, it?s now August 14th, 2024, with no response via email or USPS.
Does Progressive / ASI PREFERRED INSURANCE CORP plan on reinspecting or sending an engineer or other expert? If so, when? If not, why?
Finally, it appears Progressive / ASI PREFERRED INSURANCE CORP has failed to comply with Statute FS627.70131(1)(a)(b)(2) requiring a responsive acknowledgement and reply to our written claim communications within 7 days. Please advise if we are mistaken in our understanding of this.
§627.70131(1)(a) - Upon an insurer’s receiving a communication with respect to a claim, the insurer shall, within 7 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer’s claim file and dated. A communication made to or by a representative of an insurer with respect to a claim shall constitute communication to or by the insurer.
§627.70131(2) - Such acknowledgment must be responsive to the communication. If the communication constitutes a notification of a claim, unless the acknowledgment reasonably advises the claimant that the claim appears not to be covered by the insurer, the acknowledgment must provide necessary claim forms, and instructions, including an appropriate telephone number.
After not receiving any update from ASI, Ms. Norton another email to Mr. Barker on August 21, 2024:
To whom it may concern,
We are following up on the emails sent on July 27th, 2024, August 14th,
2024, and this email. We submitted our Letter of Representation, Contract and requested a true copy of the insurance policy, including declarations page, and any other claim related documents and letters via email at 3:08PM on July 27th, 2024. We followed up with an email on August 14, 2024, and now its August 21st, 2024, with no response via email or USPS.
On July 29th, 2024, Matthew from Progressive / ASI PREFERRED INSURANCE CORP reached out to Brian Ragin (another Public Adjuster on this file) via phone and told Brian he would be sending an email over requesting information and providing the information we requested.
It?s now August 21st, 2024, with no response via email or USPS. Does Progressive / ASI PREFERRED INSURANCE CORP plan on reinspecting or sending another adjuster, engineer, or other expert? If so, when? If not, why?
On August 23, 2024 Kathryn Dean (FL Lic. #W440279), Sr. Complex Claims Adjuster, finally emailed the Insured's public adjusters and advised she is assisting Mr. Barker with the claim until his return on September 3rd. She also included a letter that included a certified copy of the policy and advised that ASI was handling the claim under a Reservation of Rights. Ms. Dean's letter stated in pertinent part the following:
We acknowledge and confirm receipt of your letter of representation for the above-referenced claim regarding damages that are alleged to have occurred on July 23, 2024, at 4305 SHIRLEY AVE. It is our intent to promptly adjust and investigate your client’s loss, but please accept this letter as notice that we are proceeding with our adjustment of your client’s claim under a Reservation of Rights.
We also acknowledge your firm's request for a copy of your client’s policy. We will forward you a copy of the documents available to you within two weeks from the date of this letter.
We have responded to your client’s claim by contacting you, discussing the claims process, and assigning an independent field adjuster. They will contact your office to schedule their inspection.
In order for us to complete our investigation, we need the below requested information from your client:
· Receipts/invoices for any recent work/repair completed to the covered garage from felled tree (claim number 331705-151013), dwelling roof replacement (claim number 623570-191013), and breezeway and patio roof replacement as well as exterior bricks (claim number 687699-191013). All receipts will need to note what repairs were completed, who completed the repairs, verifiable contact number, address, tax id, and when repairs were completed,
· Receipts for any payments made by your client to date (front & back of cancelled check and/or documentation noting withdraw from financial institution),
· Any photos taken by the loss consultant, insured, or their representatives,
· Tree removal receipt/invoice,
· Receipt/invoice for claimed bed.
After we receive and review the requested information, additional information may still be required. At this time, we need a recorded interview with the named insured(s), Sterling Cox. I ask you to contact me to coordinate the recorded statement of Sterling Cox. I can be reached at 440-566-8712. The statement can easily take place Monday through Friday between the hours of 8:00 AM and 5:00 PM if completed via telephone. Should you be unavailable during these hours, we may be able to make other accommodations.
Your client’s policy contains conditions, limitations, or provisions that limits coverage for the following items reported as damaged under this claim:
- Water Damage Exclusion Endorsement,
- Limited Water Damage Coverage Endorsement
Please note that the policy in force for the claimed loss contains specific duties after loss which must be performed either by the named insureds or their representative.
- Make reasonable and necessary repairs to protect the property,
- Provide us with records and documents we request,
- Submit to a recorded statement.
Please refer to your client’s Policy Form HO 00 03 04 91, as amended by the ASI HO 09 SP 12 13...Please understand that our willingness to investigate this claim does not constitute a waiver of any rights under the policy. Please do not construe this letter or any act or failure to act on our part, or any agent or representative of ours as a waiver of any rights or defenses available to us by contract or at law, as all such rights and defenses are hereby specifically reserved, nor do we waive any of your duties after loss as defined by the policy and listed above.
The company's position relative to coverage will be stated upon completion of its investigation.
Should you have any questions in regards to the matters set forth in this letter, please call me at 440-566-8712.
In addition, Ms. Dean sent another letter dated August 23, 2024, without any explanation and in violation of Florida Statute Section 627.70131(6)(a) and (b), that the Insurance Company determined the claim presented was covered based on the observations of the initial field adjuster but a claim payment was not issued. The Insurance Company’s correspondence failed to provide a detailed and specific explanation of its basis for why an undisputed claim payment was not issued and what, if anything was needed for a pay,ent to be sent, as this letter contradicted the evidence and information provided by the Insured supporting fully payment under the Policy and the prior letter sent by Ms. Dean requesting a plethora of irrelevant documents from the Insured. Further the Insurance Company’s correspondence inaccurately undervalued coverage for the Insured’s damages, and otherwise contrary to the evidence and documentation submitted by the Insured and his public adjuster. Specifically, ASI advised in pertinent part the following:
Coverage has been requested under policy number FLP71186 for the policy period from August 31, 2023 to August 31, 2024. In response to the reported claim, we have completed our initial inspection of your property.
Enclosed you will find a copy of our adjuster’s Initial Estimate, which we are required to provide to you under Florida Statutes, § 627.70131(3)(e).
The enclosed Initial Estimate simply reflects the conditions observed by the adjuster at the time of the inspection. Coverage under your insurance policy has not been determined at this time. We are reviewing the results of the inspection and the terms of your policy, and we will advise you of our coverage determination as soon as possible. If the loss is covered by your policy, a finalized estimate of the covered damage will be provided with our coverage determination letter.
Additionally, please note that the Initial Estimate contains the following statement:
THIS ESTIMATE REPRESENTS OUR CURRENT EVALUATION OF THE COVERED DAMAGES TO YO INSURED PROPERTY AND MAY BE REVISED AS WE CONTINUE TO EVALUATE YOUR CLAIM. IF YOU HA QUESTIONS, CONCERNS, OR ADDITIONAL INFORMATION REGARDING YOUR CLAIM, WE ENCOURAGE TO CONTACT US.
Florida Statutes, § 627.70131(6)(a) requires us to include this statement on any preliminary or partial estimate. As stated above, coverage under the policy has not been determined at this time. The inclusion of this statutorily required statement in your Initial Estimate should not be read, construed, or understood to imply or state that the conditions observed by the adjuster are covered by your policy.
It should be noted that the estimate enclosed with Ms. Dean’s August 23, 2024 letter substantially undervalued the Insured’s damages as previously mentioned and based on Mr. Lawman’s observations the total coverage amount was only $15,235.26. In addition, due to the scope and amount of structural damage at the Property, the Insured hired Lucas & Scott Engineering, Inc. on August 23, 2024, to perform a structural assessment of the roof framing damage to the subject residence. Mr. Douglas V. Lucas, P.E. performed a site visit on August 23, 2024, to evaluate the roof framing damage. Mr. Lucas inspected the single-story building built in 1927 with brick exterior walls, conventionally framed roof system. Based on Mr. Lucas’ inspection his report which was provided to ASI by the Insured’s public adjuster stated in pertinent part the following:
Summary and Conclusions
The following conclusions were made after our site visit and a review of the field notes and photographs. Our opinions are as follows:
1. The (6) damaged roof rafters and (5) damaged ceiling joists will need to be replaced as they cannot be repaired.
2. New hurricane clips will need to be added to each repaired ceiling joist/rafter pair.
3. The damaged roof decking is 1x6 and will need to be replace in the damaged area.
4. Approximately 8’-0” of the purlin has been damaged and will need to be replaced along with the 2x4 braces that support the horizontal purlin.
5. The stair-step cracks in the mortar around the corner window will need to be repaired. The cracked bricks at the top of the wall will need to be replaced.
6. The damaged beam and rafters at the carport will need to be replaced due to the twisting of the carport.
Observations
Observations made during our site visit are summarized below:
• The subject residence was located at 4305 Shirley Avenue in Jacksonville, Florida (Photographs 1-4). The structure is a single-story building with brick exterior walls and a conventionally framed roof system.
• There is some stair-step cracking in the mortar and cracked bricks at the right elevation (Photograph 5).
• There are (5) damaged 2x6 ceiling joists that will need to be replaced (Photographs 6-7).
• There are (6) damaged 2x6 rafters that will need to be replaced (Photograph 8).
• There is 8 feet of 2x4 purlin framing that will need to be replaced as well as roof decking (Photograph 9).
• The 2x6 carport beam and rafters are damaged and will need to be replaced (Photograph 10).
Analysis
The subject structure was located at 4305 Shirley Avenue in Jacksonville, Florida. A recently fallen tree has damaged the corner of the right elevation roof system. The roof is conventionally framed with 2x6 rafters spaced @ 24” o/c and 2x6 ceiling joists spaced @ 16” o/c. The roof rafters and ceiling joists will need to be replaced as they cannot be repaired. The rafters and ceiling joists will need to be connected together at the plate and new hurricane clips will need to be added to each repaired ceiling joist/rafter pair.
The damaged roof decking is 1x6 and will need to be replace in the damaged area. The rafters are supported along the midspan on a 2x4 wood framed purlin system. Approximately 8’-0” of the purlin has been damaged and will need to be replaced along with the 2x4 braces that support the horizontal purlin.
The right elevation experienced movement during the impact with the large tree. The impact had initiated stair-step cracks in the mortar around the corner window as well as a couple of cracked bricks at the top of the wall. The cracked bricks will need to be replaced. The carport sustained racking and damage to the rafters and beam. The damaged beam and rafters will need to be replaced due to the twisting of the carport.
On or about 9/5/2024, the Insured’s public adjuster relayed the Insured’s coverage dispute and demanded the Insurance company for payment in full as referenced in their Sworn Statement in Proof of Loss (“POL”) which complied with all enumerated policy requirements and delineated both the replacement cost and actual cash value of the loss and any additional damages owed to the Insured. The POL, in the amount of $216,731.81 represented the Replacement Cost Value and $211,760.86 at actual cash value of the claim and took into account the deduction of the $500.00 deductible and $4,970.95 in recoverable depreciation as referenced in the comprehensive Xactimate Repair Estimate, photographs, invoices and supporting engineering documentation. This was immediately presented to ASI for review and to assist in a timely resolution of the subject claim. In addition, Ms. Norton emailed ASI all of the documents from the prior claims that were submitted to ASI by Insured going back to 2018 and provided proof of repairs for same. The extensive documentation was more than what was asked for by ASI and further evidenced the Insured’s compliance with his duties after loss entitling him to full payment under the Policy.
On September 20, 2024, Mathew Barker emailed the Insured's public adjuster advising that ASI will need to reinspect the loss with an engineer and attached another status letter to his email. ASI's letter dated September 16, 2024 stated the following:
This letter is in response to the first notice of loss notice received on July 23, 2024, for claim number 1390677-241013 at ASI Preferred Insurance Corp. We are sending you this notification in compliance with Florida Statute 627.70131(7)(a), which states in part as follows:
Within 60 days after an insurer receives notice of a property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay such claim or a portion of the claim is caused by factors beyond the control of the insurer.
ASI's investigation and evaluation of the above-referenced claim continues. As of this date, ASI Preferred Insurance Corp (ASI) is unable to confirm whether or not coverage is available for the above-referenced claim or a portion of it pursuant to ASI homeowners' policy # FLP71186 (policy period from August 31, 2023, to August 31,2024) (the subject ASI policy) because ASI has not received all information necessary to properly evaluate this claim. As you are aware, we are currently awaiting receipt of the following material claims information to assist ASI in its ongoing investigation and evaluation:
Proof of prior repairs
Inspection conducted by engineer and the report for review to address damages sustained to the home by the fallen tree.
Pursuant to F.S. 627.70131(8)(b), please provide the material claims information within ten (10) days. Additional or other information and/or analysis may be sought by ASI in the future regarding this claim before a coverage decision is made, and this letter should not be construed as an acceptance or rejection of coverage by ASI relative to this claim or as a decision by ASI to pay or deny this claim, or any portion thereof.
However, Mr. Barker's letter misrepresented law and facts as his request for information was untimely and in violation of F.S. 627.70131(8)(b). Specifically, Mr. Barker must have forgotten the latter half of the subsection he was trying to utilize to delay ASI's obligation to issue its coverage determination within 60 days upon receiving notice of the loss by the Insured. Specifically, the 60 day deadline to issue its coverage determination, is tolled under subsection (8)(b) only when "requests sent by the insurer to the policyholder or a representative of the policyholder at least 15 days before the insurer is required to pay or deny the claim or a portion of the claim under subsection (7)." Mr. Barker sent his email on September 20, 2024 with a backdated letter of September 16, 2024 only two days prior to the deadline for ASI to issue its coverage determination.
In addition, the documentation that ASI is advising it is in need of was already provided by Ms. Norton via her letter that was forwarded to ASI on September 5, 2024. Moreover, Ms. Norton demanded ASI to respond to her correspondence within seven (7) days if there were anything else it needed to complete its investigation of the Loss and that if it did not respond to her, then it would be understood that ASI had everything it needed in its possession to conclude its investigation, and payment would be issued for the amount demanded by the Insured in the duly executed Proof of Loss Form. It was not until the 15th day from her letter being sent that Mr. Barker decided to email and backdate a letter in an attempt to unreasonably delay the resolution of this claim and in violation of Florida Statute §violation of Florida Statute 627.70131 (1)(a), which states, "[u]pon an insurer’s receiving communication with respect to a claim, the insurer shall, within 7 calendar days, review and acknowledge receipt of such communication unless payment is made within that period of time or unless the failure to acknowledge is caused by factors beyond the control of the insurer. If the acknowledgment is not in writing, a notification indicating acknowledgment shall be made in the insurer’s claim file and dated. A communication made to or by a representative of an insurer with respect to a claim shall constitute communication to or by the insurer." Further, This letter and the information communication by Mr. Barker is a clear violation of Florida Statute 626.9541(1)i(2) "material misrepresentation(s) made to the insured, the Insured’s public adjuster as they had an interest in the proceeds payable under such contract or policy, for the sole purpose and with the intent of effecting settlement of such claims, loss, or damage under such contract or policy on less favorable terms than those provided in, and contemplated by, such contract or policy." Additionally, ASI violated Section 626.9541(1)(i)(3)(b), Fla. Stat., when Mr. Barker misrepresented pertinent facts or insurance policy provisions relating to coverages at issue.
On September 24, 2024 Ms. Norton responded to Mr. Barker's email with the following disputing ASI's unreasonable and unjustifiable delays:
Hi Matthew,
We are in receipt of your email dated September 20, 2024, stating the following:
“We will need to reinspect the loss with an engineer. They will reach out to schedule inspection. Status letter attached."
On July 27, 2024, we submitted our contract and letter of representation to Progressive/ASI. To our knowledge, Progressive/ASI did not acknowledge or respond until August 23, 2024 (27 days later).
On August 14, 2024 (and again on August 21, 2024), we sent emails to Progressive/ASI asking the following questions, “Does Progressive/ASI plan on reinspecting or sending another adjuster, engineer, or other expert? If so, when? If not, why?”
We received no response to these emails until September 20, 2024 (37 days later), when via email Progressive/ASI requested to reinspect with an engineer. In case this is not overly obvious, we want to point out this could have been scheduled long before now and shows Progressive/ASI waited until the 57th day after the loss to request to reinspect with an engineer. We note no reason was given for waiting this long to request an engineer.
We are also in receipt of the Status Letter dated September 16, 2024, that was attached to the email sent on September 20th, 2024, with no explanation for not sending the letter on September 16, 2024. The status letter states in part:
“Within 60 days after an insurer receives notice of a property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay such claim or a portion of the claim is caused by factors beyond the control of the insurer.” (Emphasis added by Matthew Barker)
It is unclear why that statute language was used in that letter, or why you emphasized "Within 60 days," or why it appears you did not use the current (or complete) statute language. The current statute section 627.70131(7)(a) reads as follows:
"Within 60 days after an insurer receives notice of an initial, reopened, or supplemental property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay is caused by factors beyond the control of the insurer. The insurer shall provide a reasonable explanation in writing to the policyholder of the basis in the insurance policy, in relation to the facts or applicable law, for the payment, denial, or partial denial of a claim. If the insurer’s claim payment is less than specified in any insurer’s detailed estimate of the amount of the loss, the insurer must provide a reasonable explanation in writing of the difference to the policyholder. Any payment of an initial or supplemental claim or portion of such claim made 60 days after the insurer receives notice of the claim, or made after the expiration of any additional timeframe provided to pay or deny a claim or a portion of a claim made pursuant to an order of the office finding factors beyond the control of the insurer, whichever is later, bears interest at the rate set forth in s. 55.03. Interest begins to accrue from the date the insurer receives notice of the claim. The provisions of this subsection may not be waived, voided, or nullified by the terms of the insurance policy. If there is a right to prejudgment interest, the insured must select whether to receive prejudgment interest or interest under this subsection. Interest is payable when the claim or portion of the claim is paid. Failure to comply with this subsection constitutes a violation of this code. However, failure to comply with this subsection does not form the sole basis for a private cause of action."
Contrary to statutes, it appears Progressive/ASI has failed to acknowledge or respond to written claim communications within 7 days, has failed to pay or deny the claim or any part of the claim within 60 days, has failed to provide a reasonable explanation for failing to pay or deny within 60 days, has failed to make a payment based on its own detailed estimate of the amount of the loss, and has failed to explain why payment was not made based on its own detailed estimate. It remains unknown whether or not Progressive/ASI sent a copy of any detailed estimate of the amount of the loss within 7 days after the estimate was generated by the insurer’s adjuster, and we request evidence of same. It also appears interest is owed from the date Progressive/ASI received notice of the claim on July 23, 2024.
We must note that your being on vacation until September 3, 2024, per the email sent on August 23, 2024, from Kathryn Dean, and not responding to claims communications within 7 days does not fall under delays “caused by factors beyond the control of the insurer.” Furthermore, with the status letter requesting “Proof of prior repairs”, it appears that Progressive/ASI is continuing to delay the claim process by requesting information that it already has in its possession, apparently to avoid its duty to properly indemnify Mr. Cox for the covered loss, to the detriment of the Insured.
All requested information on prior claims, including paid receipts constituting proof of prior repairs, was provided to Progressive/ASI via email on September 5, 2024. In addition to the documents being provided in an email on September 5, 2024, in the letter dated September 5, 2024, RE: RESERVATION OF RIGHTS & DOCUMENT REQUEST LETTER that was attached to that email, it clearly states the following “If I do not receive a written response in the next seven (7) days, I will infer that ASI has all the information in its possession to conclude its investigation and will await payment in the amount demanded for my client’s covered loss.” We did not receive any request for additional information in response to the September 5, 2024, communications until September 20, 2024, well after the 7 days expired, and the requested information had already been provided. If there is something more specific, that has not already been provided, please advise.
Thereafter, the Insured received two letters dated September 26, 2024 acknowledging receipt of Gold Star's estimate "that was provided to ASI on September 10, 2024 and advised it had issued a settlement of the claim and that the appraisal process is ongoing and once the executed award is received and reviewed, ASI would follow up with you." This letter is wholly inaccurate as the Insured never received any undisputed claim payment and a settlement was never reached. In addition, the appraisal process did not even commence nor was it demanded by either party. Additionally, Gold Star received another letter dated September 26, 2024 from Mr. Barker with the same formatted language advising "This letter is to acknowledge receipt of your estimate in the amount of $217,231.81 dated and received in our office on xxx. Please understand that our receipt of the estimate is not to be construed or deemed to be our acceptance or agreement with the contents of the estimate. We have responded to your claim by contacting you and discussing the claims process. At this time, we have requested an engineer to reinspect the loss."
The two letters authored by Mr. Barker on behalf of ASI clearly show the improper claims adjustment and handling by ASI in this matter. Mr. Barker and other representatives are unjustifiably denying and delaying investigations of otherwise covered claims by using templated letters instead of actually reviewing evidence and documentation provided by its Insureds and public adjuster to amicably conclude claims in a fair and timely manner. As such, ASI has violated F.S. §626.9541(1)(i)(2) - A material misrepresentation made to an insured or any other person having an interest in the proceeds payable under such contract or policy, for the purpose and with the intent of effecting settlement of such claims, loss, or damage under such contract or policy on less favorable terms than those provided in, and contemplated by, such contract or policy; §626.9541(1)(i)(3)(a) - Failing to adopt and implement standards for the proper investigation of claims; §626.9541(1)(i)(3)(b) - Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue; §626.9541(1)(i)(3)(g) - Failing to promptly notify the insured of any additional information necessary for the processing of a claim; and §626.9541(1)(i)(3)(h) - Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
However, what ASI and Mr. Barker failed to realize is that they already determined the Insured's loss was covered but wholly undervalued the Insured's damages pursuant to its letter dated August 23rd which included the repair estimate from David Lawman advising the Insured’s damages were only $15,235.26. As such, there was no reason to continue to delay the resolution of this action other than to find ways to underpay, deny and otherwise find ways to pay as little as it could possibly pay to the Insured for his catastrophic loss of at least $200,000+ as demanded by Gold Star. This is further evidence of ASI's willful and intentional violations of the following Florida Statutes: §626.9541(1)(i)(4) - Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 60 after an insurer receives notice of a residential property insurance claim, determines the amounts of partial or full benefits, and agrees to coverage, unless payment of the undisputed benefits is prevented by an act of God, prevented by the impossibility of performance, or due to actions by the insured or claimant that constitute fraud, lack of cooperation, or intentional misrepresentation regarding the claim for which benefits are owed; §624.155(1)(b)(1) - Not attempting in good faith to settle claims when, under all circumstances, it could have and should have done so, had it acted fairly and honestly toward its Insured and with due regard.; §624.155(1)(b)(3) - Except as to liability coverages, failing to promptly settle claims, when the obligation to settle a claim has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage; and §626.9541(1)(i)(3)(a) - Failing to adopt and implement standards for the proper investigation of claims.
On October 24, 2024 after not receiving any correspondence from Mr. Barker following the engineer’s inspection on October 2, 2024, Ms. Norton sent the following email:
Hi Matthew,
As you are aware, ASI/Progressive had sixty (60) days from the date this claim was reported by the Insured to render a coverage determination (September 21, 2024) as required under the Policy and Florida Statute 627.70131(7)(a):
“(7)(a) Within 60 days after an insurer receives notice of an initial, reopened, or supplemental property insurance claim from a policyholder, the insurer shall pay or deny such claim or a portion of the claim unless the failure to pay is caused by factors beyond the control of the insurer. The insurer shall provide a reasonable explanation in writing to the policyholder of the basis in the insurance policy, in relation to the facts or applicable law, for the payment, denial, or partial denial of a claim. If the insurer’s claim payment is less than specified in any insurer’s detailed estimate of the amount of the loss, the insurer must provide a reasonable explanation in writing of the difference to the policyholder. Any payment of an initial or supplemental claim or portion of such claim made 60 days after the insurer receives notice of the claim, or made after the expiration of any additional timeframe provided to pay or deny a claim or a portion of a claim made pursuant to an order of the office finding factors beyond the control of the insurer, whichever is later, bears interest at the rate set forth in s. 55.03. Interest begins to accrue from the date the insurer receives notice of the claim. The provisions of this subsection may not be waived, voided, or nullified by the terms of the insurance policy. If there is a right to prejudgment interest, the insured must select whether to receive prejudgment interest or interest under this subsection. Interest is payable when the claim or portion of the claim is paid. Failure to comply with this subsection constitutes a violation of this code. However, failure to comply with this subsection does not form the sole basis for a private cause of action.”
We are now 22 days since the engineer completed his field inspection on October 2, 2024, and 93 days since the reporting of the claim. It is my understanding, that Florida Statute 627.70131(8)b advises that the 60-day coverage determination requirements of 627.70131(7)(a) are paused upon the "failure of a policyholder or a representative of a policyholder to provide material claims information requested by the insurer within 10 days after the request was received. The tolling period ends upon the insurer's receipt of the requested information. Tolling under this paragraph applies only to requests sent by the insurer to the policyholder or a representative of a policyholder at least 15 days before the insurer is required to pay or deny the claim or a portion of the claim under subsection(7)."
As you are aware ASI/Progressive did not request any documentation or information from the Insured to conclude its investigation of the claim until September 26, 2024, five days after the 60-day requirement for ASI/Progressive to issue a coverage determination when it requested an engineer to inspect the insured property. However, my client in good faith allowed ASI/Progressive to have its engineer inspect the loss and otherwise substantially complied with his duties after loss. Therefore, the 60-day coverage determination deadline was not paused as referenced above as the Insured complied with all requests for material information before the 60-day coverage determination deadline. There are no longer any factors outside the control of ASI/Progressive justifying its failure to issue the coverage determination and full payment of my client's damages as previously demanded.
Therefore, on behalf of the Insured, I am demanding the insurer (Progressive/ASI) to issue its coverage determination within the next seven days and payment in full for $217,231.81 as outlined in the attached supporting documents. Furthermore, my client demands ASI's/Progressive’s compliance with Florida Statute 627.70131(7)(a) by including a payment for interest on the total amount demanded from the date the claim was reported until the date the payment in full is tendered by ASI/Progressive. If there are any reasons that are preventing ASI/Progressive from issuing payment in full, please advise in writing so the Insured can comply with his duties after loss and assist the carrier in concluding the investigation of this claim within the next seven days.
In response to that email, Ms. Norton received an automated email response from ASI “We have received your inquiry and are researching your request. Our goal is to respond within five business days. If you need immediate claims assistance, please contact your claims representative or call our toll-free automated customer service at 1-800-274-4499.Sincerely,
Progressive Group of Insurance Companies.” Five business days passed and Ms. Norton did not receive any update from ASI or a response to her most recent email demanding full coverage from ASI for the Insured’s covered loss.
Ms. Norton’s continuous and relentless emails to ASI attempting to resolve this claim evidence a systematic practice of ASI failing to communicate and timely resolve covered losses in violation of Florida Statue Statute §§ 626.9541(1)(i)(3)(c), 624.155(1)(b)(1),626.9541(1)(i)(3)(i), and 626.9541(1)(i)(3)(a). The Insurance Company has continuously breached the subject policy and has wrongfully failed to tender the coverage amount demanded by the Insured despite having evidence obliging it to do so under the Policy.
Furthermore, the Xactimate repair estimate provided to the Insurance Company by the Insured’s public adjuster and supporting damage documentation from the Insured’s engineer was explicitly contrary to any defenses/exclusions being asserted by the Insurance Company and supports every penny of what is owed to the Insured; however, this information was ignored by the Insurance Company solely to avoid payment on an otherwise clear-cut covered loss and delayed the resolution of this matter by advising an engineer needed to reinspect the loss. Notwithstanding, the Insured complied with ASI’s unnecessary request for an engineer to inspect the loss and ASI has still failed to issue full payment to the insured within 60 days form the reporting of the subject loss in violation of Florida Statute § 627.70131(8)b. It is clear that the Insurance Company’s entire adjustment was designed to defraud the insured out of the insurance benefits due and owing under the subject policy per its customary business practices.
As of the filing of Civil Remedy Notice 786787 and this Notice, the Insurance Company has clearly violated Florida Statute §626.9541(1)(i)(3)(e) as it has failed to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed. The POL was submitted on or around 9/5/2024 and approximately 63 days have elapsed since then and ASI has not issued any claim payment or denied coverage for the subject loss in violation of Florida law and in breach of the Policy.
The Insurance Company violated section 624.155(1)(b)(1), Fla. Stat., when it failed to attempt in good faith to settle the claim when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for their interests. Specifically, the Insurance Company ignored covered damages to the Property and refused to issue any payment for the claim. The Insurance Company retained outcome-oriented experts and poorly trained claim professionals to manufacture an opinion that the damages were not fully covered by the Policy. Had the Insurance Company acted fairly and honestly toward the Insured and with due regard for its interests the Insurance Company would have attempted to settle the claim rather than issue the August 17, 2024 letter wholly undervaluing the Insured’s damages. In addition, when the Insurance Company was called out on this, it sent a second estimate of damages as determined by Nathan Gibson, for only $40,455.24. The second estimate is evidence and confirmation of ASI’s violation of Florida Statute §626.9541(1)(i)(3)(j) - Altering or amending an insurance adjuster’s report without: (I) Providing a detailed explanation as to why any change that has the effect of reducing the estimate of the loss was made; and (II) Including on the report or as an addendum to the report a detailed list of all changes made to the report and the identity of the person who ordered each change; or (III) Retaining all versions of the report, and including within each such version, for each change made within such version of the report, the identity of each person who made or ordered such change.
The Insurance Company also violated sections 626.9541(1)(i)(2) and 626.9541(1)(i)(3)(b), Fla. Stat., when it made material misrepresentations to the Insured that the Exterior: Awning, Masonry-Brick Veneer, Framing (including Roof Trusses), Shingle Roofing System, Flat Roofing System, Gutters; Interior: Kitchen, Dining Room, Living Room, Hallway, Bedroom 1, Bedroom 2, Bedroom 3 at the Property were not fully damaged by windstorm and/or fallen tree or any other peril for which the policy afforded full coverage for the replacement of same. This material misrepresentation was made for the purpose and with the intent of settling the claim on less favorable terms than those provided in and contemplated by the Policy. In fact, the Insurance Company’s entire adjustment was designed to defraud the Insured out of the insurance benefits due and owing under the subject policy per its customary business practices.
The Insurance Company violated section 626.9541(1)(i)(3)(d), Fla. Stat., when it decided to delay and fail to issue any claim payment to the Insured without conducting a reasonable investigation based upon all available information provided by the Insured’s public adjusters. The Insurance Company failed to adequately consider the entirety of the information provided by the Insured and/or their representatives in support of coverage for the claim. Within every insurance policy is an implicit duty of good faith and fair dealing. This duty of good faith obligates the insurer to handle its insured’s claims with “the same degree of care and diligence as a person of ordinary care and prudence should exercise in the management of his own business.” Boston Old Colony Ins. Co. v. Gutierrez, 386 So. 2d 783 (Fla. 1980). The Insurance Company had a duty to act in good faith and with due regard for the interests of the Insured but failed to do so.
The entire purpose of insurance is to indemnify the Insured of a covered loss. Despite the fact that the Insurance Company knows, or should know, that benefits are owed based upon the information provided by the Insured, to date, the Insurance Company has failed to issue any payment under the Policy, whether undisputed or otherwise. The Insurance Company’s delay in this matter is clearly against its Insured’s interests and only exacerbates the harm and hardship sustained by the Insured in connection with this loss. This is a violation of the Policy and Florida law, and if the Insurance Company handles all of its claims in accordance with the way it handled this claim, then this evidences a systematic practice of adjusting claims without due regard for the objective best interest of its Insureds. The Insured has complied with all requests made by the Insurance Company and provided all the information available to them with respect to the loss. Even though the Insured has complied with all other post loss obligations under the Policy, the Insurance Company continues to deny payment to the Insured that is due and owing under the Policy. This delay continues to exacerbate the damages incurred by the Insured, such as experiencing additional damaged to the home from Hurricane Helene and Hurricane Milton as the tarp on the roof was not a permanent repair but the only option the Insured had to mitigate his damages following the Loss due to ASI’s failure to timely resolve and issue full payment under the Policy.
The Insurance Company’s conduct has been reckless and unfair to the Insured. The Insurance Company has a contractual obligation not to look the other way when confronted with facts revealing the possibility of coverage and resisting reasonable interpretations of its policy. This is a breach of the Policy. The concept of insurance is that insurance is the insurer’s granting of timely and prompt indemnity or security against a contingent loss. Florida Statute §624.02 defines “insurance” as a contract whereby one undertakes to indemnify another or pay or allow specified amount or a determinable benefit upon determinable contingencies. Inherent is the fact that payment must be made timely and promptly so that the Insured may mitigate the damages and to put the Insured back into the position he/she was in prior to the loss as quickly as possible. The Insurance Company has breached this duty. The Insurance Company has refused and/or failed to tender any insurance proceeds to the Insured upon demand. The Insurance Company’s refusal and/or failure to settle the insurance claim, when under all circumstances it could have and should have done so had it acted fairly and honestly towards the Insured, is wrongful conduct. Furthermore, the Insured contends that the Insurance Company’s adjusters and/or representatives financially benefit by such wrongful conduct.
Moreover, it is clear from the above that the Insurance Company has failed to implement standards for the proper investigation of the claim to the detriment of the insured. As a result, the Insurance Company has violated the following sections of Florida Statutes:
§624.155(1)(b)(1) - Not attempting in good faith to settle claims when, under all circumstances, it could have and should have done so, had it acted fairly and honestly toward its Insured and with due regard.
§624.155(1)(b)(3) - Except as to liability coverages, failing to promptly settle claims, when the obligation to settle a claim has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.
§626.9541(1)(i)(2) - A material misrepresentation made to an insured or any other person having an interest in the proceeds payable under such contract or policy, for the purpose and with the intent of effecting settlement of such claims, loss, or damage under such contract or policy on less favorable terms than those provided in, and contemplated by, such contract or policy.
§626.9541(1)(i)(3)(a) - Failing to adopt and implement standards for the proper investigation of claims.
§626.9541(1)(i)(3)(b) - Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
§626.9541(1)(i)(3)(c) - Failing to acknowledge and act promptly upon communications with respect to claims.
§626.9541(1)(i)(3)(e) - Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
§626.9541(1)(i)(3)(f) - Failing to promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement.
§626.9541(1)(i)(3)(g) - Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
§626.9541(1)(i)(3)(h) - Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
§626.9541(1)(i)(4) - Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 60 after an insurer receives notice of a residential property insurance claim, determines the amounts of partial or full benefits, and agrees to coverage, unless payment of the undisputed benefits is prevented by an act of God, prevented by the impossibility of performance, or due to actions by the insured or claimant that constitute fraud, lack of cooperation, or intentional misrepresentation regarding the claim for which benefits are owed.
Additionally, through its actions/inactions, subject to the facts and circumstances understood at this time as outlined herein, the Insurance Company and their representatives have failed to comply with the following sections of Florida Administrative Code:
69B-220.201(3)(b) - An adjuster shall treat all claimants equally.
69B-220.201(3)(b)(1) - An adjuster shall not provide favored treatment to any claimant.
69B-220.201(3)(b)(2) - An adjuster shall adjust all claims strictly in accordance with the insurance contract.
69B-220.201(3)(c) - An adjuster shall not approach investigations, adjustments, and settlements in a manner prejudicial to the insured.
69B-220.201(3)(d) - An adjuster shall make truthful and unbiased reports of the facts after making a complete investigation.
69B-220.201(3)(e) - An adjuster shall handle every adjustment and settlement with honesty and integrity and allow a fair adjustment or settlement to all parties without any compensation or remuneration to himself or herself except that to which he or she is legally entitled.
69B-220.201(3)(f) - An adjuster, upon undertaking the handling of a claim, shall act with dispatch and due diligence in achieving a proper disposition of the claim.
69B-220.201(3)(j) - An adjuster shall not knowingly fail to advise a claimant of the claimant’s claim options in accordance with the terms and conditions of the insurance contract.
69B-220.201(3)(k) - An adjuster shall not undertake the adjustment of any claim concerning which the adjuster is not currently competent and knowledgeable as to the terms and conditions of the insurance coverage, or which otherwise exceeds the adjuster’s current expertise.
As a direct result of the Insurance Company 's actions, the insured have sustained irreparable harm. Upon information and belief, the aforementioned actions complained of herein, among others, are effectuated by the Insurance Company so often as to constitute a general business practice evidencing a motive to enhance the Insurance Company's profits and cause a detrimental effect to its policyholders. The Insurance Company clearly failed to adopt and implement standards for the proper investigations of claims. As a direct and proximate result of the Insurance Company's handling of the claim, the insured sustained extra-contractual damages, including, but not limited to, a public adjuster's fee and additional costs for emergency mitigation services that would have otherwise not been needed. The Insurance Company's implemented claims programs and practices that were improper which directly resulted in additional losses to its insured. The Insurance Company, as part of its routine business pattern and practices, employs outcome-oriented adjusters/vendors/experts who purposely looked for ways to minimize coverage instead of affording coverage to its policyholders. In contrast to the legislative intent which motivated the enumeration of an insurance adjuster’s responsibilities outlined in the Florida Administrative Code, the insureds were not afforded the professional duties entrusted and imposed on the Insurance Company by the Public Trust. The outcome-oriented claim adjustment practices undertaken by the Insurance Company led to the Insurance Company's failure to adequately adjust the Claim. The Insurance Company, as a matter of its routine business practices, ignores correspondences, emails, letters, phone calls, voicemails, and the like from its insureds and/or their representatives. Any attempt to contact someone via email is impossible as the only email address utilized is a general claims email which is seemingly unmonitored and any attempt to contact someone via telephone results in extensive amounts of time navigating menus and assistants who transfer calls between departments until the phoneline either goes dead or a voicemail is reached. Even after leaving a voicemail, no return phone call or any other form of communication is received by the Insured in response in violation of §626.9541(1)(i)(3)(c).
The Insurance Company has purposely created an unnavigable labyrinth designed with the hopes of causing its insureds enough frustration that they ultimately cease to pursue their claims. Additionally, The Insurance Company sends correspondences requesting numerous overbroad categories of documents that are irrelevant and/or already been provided to the Insurance Company by the Insured. Said document requests do not contain any explanation as to why such information is necessary. Typically, said document requests are sent prior to the issuance of any payment by the Insurance Company so as to delay the issuance of the insureds' undisputed coverage proceeds or along with said payments despite no presentation of a discrepancy or need for reservation of rights. Regardless of the timeline in the claim in which the documents are requested and/or an insureds' level of compliance with the document and proof of loss request, the Insurance Company fails to take any further action and, instead, fails to acknowledge/act promptly upon all subsequent communications including, but not limited to, demands for coverage and payment. Based on the knowledge of the Insured’s counsel the bad faith behavior perpetrated by the Insurance Company occurs so frequently as to indicate a general business practice.
There is clear evidence in counsel's own files of willful, wanton, and malicious actions perpetrated by the Insurance Company in reckless disregard for the rights of its insureds. As such, it is clear that the Insurance Company’s repeated and generally utilized business practices violate Florida Statutes 624 and 626, as well as the Florida Administrative Code governing adjusters' ethical requirements, and the pattern and practice of de facto bad faith adjustment tactics can be established without the need for any further investigation of the Insurance Company’s claim files or file management system. In fact, the filing counsel has kept track of all the Insurance Company’s claims in which he has provided representation which include but are not limited to CRNs filed with The Department of Financial Services, in which substantially similar bad faith conduct has taken place. Such conduct occurs so frequently as to indicate a general business practice. The following is a non-exhaustive list of the files indicating same:
1. Kessel– ASI Claim No. 1304085-241013; CRN Filing # 777089 **(Mr. Barker was also involved in this claim and performed the same bad faith actions and/or violations as this matter)**
2. Yi – ASI No. 1021089-221013; CRN Filing # 642256
3. Rex– ASI Claim No. 11211294-221001; CRN Filing # 676413
4. Jaffe – ASI Claim No. 972304-211013; CRN Filing #613756
5. Jaffe – ASI Claim No.: 972304-211013; CRN Filing #623567 and 634832
5. Oreste – ASI Claim No. 988140-11013; CRN Filing #616694
6. Hewitt– ASI Claim No. 985447-211013; CRN Filing #616949
7. Parilla – ASI Claim No. 927640-211013
9. Escobar – ASI Claim No. 834580-201013
10. Parker – ASI Claim No. 890182-211013
11. Manolov – ASI Claim No. 767143-201013; CRN Filing #545098 & 579245
12. Manolov -ASI Claim No. 902080-21101; CRN Filing #579240
12. Wallace– ASI Claim No. 59-38T6-89V
13. Harris – ASI Claim No. 487698-171013; CRN Filing #396910
14. CAJIGAS – ASI Claim No. 775340-201003; CRN Filing # 514234
15. Cox – ASI Claim No.: 1390677-241013; CRN Filing #786787
Based on the above, it is clear that the Insurance Company must have a reason to act with such blatant disregard to policy, statute, rules, code, and procedure. The only possible motive an insurance company could have to act in such an egregious manner is that the Insurance Company is somehow benefiting financially through its bad faith actions. If a financial motive for acting in bad faith proves to be true, the Insurance Company, and, through the piercing of the Insurance Company’s corporate veil, its officers individually, should be monetarily sanctioned by all entities governing insurance in the State of Florida but also its license to write new insurance policies should be suspended until such a time as it has indemnified all outstanding claims.
Since the reporting of the claim, the Insurance Company failed to complete a thorough and unbiased evaluation of the damage, despite being provided substantial evidence and information from the Insured proving otherwise, and has failed to amicably resolve the loss. These failures have caused additional damages and financial harm to the Insured in direct violation of the governing policy between the Insured and the Insurer as mentioned herein. The entire adjustment of the claim was handled improperly and has resulted in additional stress, and damage to the Insured and the Property. It has now been 106 days since the loss was reported to the Insurance Company and the Insured is still left with a home in disrepair that has the potential to cause numerous safety hazards and harm to the Insured and their family members during the peak of the 2024 Atlantic Hurricane Season. Additionally, due to the bad faith adjustment of the subject claim, the Insured suffered additional harm in the form of damages from suffering through two major hurricanes (Helene and Milton).
The actions and inactions taken by the Insurance Company is evidence of the Insurance Company’s attempts to use the policy provisions to its advantage in violation of Florida Statute Section 626.9541(1)(i)(3)(b) and to limit its exposure in deliberately withholding adequate claim payments. There was no reason why the Insurance Company could not have tendered the full amount requested and owed to the Insured to repair their damages to their after receiving the documents submitted by their claim professionals and being put on notice of the claim dispute. Moreover, this is further evidence of Insurance Company’s violations of Florida Statutes 626.9541(1)(i)(3)(a), 626.9541(1)(i)(3)(b), 626.9541(1)(i)(3)(c), §626.9541(1)(i)(3)(d), 626.9541(1)(i)(3)(f), 626.9541(1)(i)(3)(i); Florida Statute, Section 624.155(b)(2); and Section 626.9531(1)(i)(3)(e).
The Florida Department of Financial Services cannot continue to allow this egregious behavior and meritless actions to delay the resolution of this claim by failing to communicate, conduct shoddy and repetitive inspections, and force the Insured to jump through unnecessary hoops to receive the insurance benefits rightfully owed to them due to the Insurance Company’s inability to investigate and handle claim disputes properly. Further, the Insured’s claim remains unresolved despite clear evidence to afford full coverage and the Insured’s strict compliance with the Policy and each and every one of the Insurance Company’s unreasonable requests. This is wholly unacceptable, and the Insurance Company cannot continue to sit back and enjoy the profits it continues to collect by engaging in the repeated business practices outlined in this Civil Remedy Notice. The Insured hereby requests the Florida Department of Financial Services to investigate the Insurance Company’s repeated business practices and take corrective measures to ensure additional consumers do not suffer and endure the additional stress and hardship they have and will continue to endure until this claim resolves.
In light of the foregoing, the Insured is concerned that the Insurance Company will stick to its pattern of intentional and unjustified delay of the conclusion of this claim in an effort to further drag out the investigation process; delay tendering payment in full and further prejudicing other insureds in the handling of their claims only for the sole purpose to deny claims by hiring biased experts and/or to limit an Insured’s recovery and profit by using the Policy to an Insured’s disadvantage (i.e., violating 626.9541(1)(i)(3)(i) - Unfair claim settlement practices).
The Insurance Company’s actions completely defeat the purpose of property and casualty insurance, as an insurance company should adequately compensate its insureds for covered losses properly at the outset of a claim, not after receiving hundreds of pages of documentation proving what was obvious and continuing to not even take the time to adequately review and exercising their own due diligence of the evidence provided by the Insured supporting full coverage for the covered loss.
This notice is given in order to perfect the right to pursue the civil remedy authorized by Section 624.155, Florida Statutes, should the Insurance Company fail to cure the violations set forth in this Civil Remedy Notice within the given cure period. There might be further wrongful conduct which has not yet been made known to the Insured at this time and the Insured reserves the right to amend this Notice as new information becomes available. Pursuant to Florida Statutes, Section 624.155, punitive damages may be awarded against an insurance company if the acts giving rise to the violation occur with such frequency as to indicate a general business practice and these acts are: (a) willful, wanton, and malicious; (b) in reckless disregard for the rights of any insured; or (c) in reckless disregard for the rights of a beneficiary under an insurance contract. It is the Insureds’ position that the Insurance Company engages in the practice of wrongfully delaying the claims investigation process, hiring biased experts/engineers/employees in evaluating insurance claims as a general business practice in a willful effort to increase profits and in reckless disregards for its Policyholder’s rights. This is wrongful conduct. To cure the defects outlined in this civil remedy notice, the Insurance Company must:
(1) Create and implement adequate guidelines for proper investigation and evaluation as to claims handling and for the training and supervision of employees including Mr. Barker, which will avoid future statutory violations as set forth above. Specifically, subject its claims representatives/adjusters to additional educational training as to the governing statutes and ethical codes that she is to adhere to while investigating a loss like the one at hand.
(2) Create and implement adequate guidelines for the proper investigation and evaluation of windstorm and/or fallen object losses, and for the training and supervision of employees, including independent field adjusters like Mr.Lawman, with regard to said claims, to ensure that the Insurance Company’s claim handling procedures with regard to these types of losses are adequate to stop further insureds from being treated unfairly and wrongfully.
(3) The Insurance Company must act fairly and honestly toward the Insured and with due regard to his interest in attempting to resolve the Insured’s claim and if this matter continues to remains unresolved the Insurance Company should refrain from conducting unnecessary field inspections, attend DFS mediation in bad faith with insufficient authority to resolve the entire claim dispute and other brazen defense tactics to only further drag out the “investigation” of the Loss to the Insured’s disadvantage per its repeated business practices.
(4) The Insurance Company must keep the claim open for the adjustment of any supplemental claim and payment of damages at Replacement Cost Value (RCV) as incurred and any additional unincurred costs to return the Property/Insured to pre-loss condition.
(5) The Insurance Company must immediately tender all insurance proceeds due and owing to the Insured for the fair value of the Claim which are fairly owed under the insurance policy that would reasonably place the Insured back to pre-loss condition, additional damages owed under the Policy, any statutory interest owed, public adjusting fees, attorney’s fees and costs as follows:
(a) $211,760.86 at Actual Cash Value, and $ 216,731.81 at Replacement Cost Value which reflects the application of the $500.00 deductible, the total costs of incurred repairs/emergency mitigation services of $13,790.00 ($1,100.00 tarp, $12,500.00 tree removal, and $190 Asbestos Testing) and the reimbursement of $4,970.95 in Recoverable Depreciation which reflects the remaining amount of insurance benefits owed to return the Insured and the Property to pre-loss condition.
i. This amount is based on Gold Star’s Xactimate Repair Estimate (including supporting photographs), POL, Lucas & Scott Engineering, Inc.’s report and the additional supporting documents previously provided to the Insurance Company.
ii. The Insured further demands the Insurance Company for payment of any additional damages at Replacement Cost Value as they are incurred at a future date in the event the subject claim is not amicably resolved within the next 60 days.
(b) $5,937.98 for statutory interest on the outstanding payment of $216731.81 referenced above pursuant to Florida Statute Section 627.70131 due to the 106 days this claim has remained unresolved following the reporting of the loss by the Insured, which will only increase as this claim remains open; and
(c) A reasonable amount of attorney’s fees for the Insured’s legal representation if this claim remains unresolved and a Property Insurance Notice of Intent to Initiate Litigation is filed pursuant to Florida Statute § 627.70152.
As such, the Insured hereby requests the Insurance Company to issue payments as reflected in Section 5 as referenced above before the expiration of the 60-day cure period. If the Insurance Company disagrees with the extent of the cure requested or asserts that the payment of any of the above cure categories may not be required, it should cure to the extent it believes it must under the Subject Policy and governing laws to correct the allegations of bad faith contained herein. However, per the Insurance Company’s standard business practices, it will not attempt to amicably resolve this claim despite its obligation to do so as referenced previously in this Notice, and the Insured will wait to receive the Insurance Company’s standard form letter from its defense counsel further delaying the resolution of this matter by alleging this CRN does not contain enough facts, policy information and what is specifically requested of the Insurer to cure the defects alleged herein which is wholly accurate. Notwithstanding, the Insured still hopes the claim can be resolved amicably and without the need for extensive litigation. However, the Insurance Company’s failure to cure the defects as described herein will result in additional extra-contractual damages and civil litigation outside of the pending action for breach of contract. While it is not being requested as a cure for the bad faith alleged herein, the Insured is willing to entertain any reasonable counteroffer of settlement.
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The submitter hereby states that this notice is given in order to perfect the rights of the
person(s) damaged to pursue civil remedies authorized by Section 624.155, Florida Statutes.
Before submitting a Notice using this system, please verify that all text has been entered
correctly and completely. Once the Notice has been submitted, the text cannot be changed
or deleted.
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DFS-10-363
Rev. 10/14/2008
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