Civil Remedy Notice of Insurer Violations
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Filing Number:     797244
Filing Accepted:  12/17/2024
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Complainant
Last/Business Name *  
CAIN   First Name   CHARLES
Street Address * 4630 EAST MARLBORO CIRCLE
City, State Zip * JACKSONVILLE, FL 32206
Email Address * CCAIN4630@AOL.COM
Complainant Type: * Insured
Insured
Last/Business Name*   CAIN   First Name   CHARLES
Policy # * 762142836 Claim #* 7006834752-1
Attorney
Attorney is Applicable
Last Name* O'NEIL First Name * JONATHAN Initial
Street Address* 203 FORT WADE ROAD, SUITE 260
City, State Zip* PONTE VEDRA , FLORIDA 32081
Email Address * JONATHAN@WOOLSEYMORCOM.COM
Violation
Insurer Type *   Authorized Insurer Unauthorized Insurer
 
Insurer Name*   TRUCK INSURANCE EXCHANGE
NAIC Company Code 21709
 
Name of individual responsible for violation (if any):* JIMMY PACHECO (FL. ADJ. LIC. W643806) AND JUDITH WELKER (FL. ADJ. LIC. #G030930)
Type of Insurance * Residential Property & Casualty   
Reason for Notice *
Claim Delay
Other : Wrongful claim denial
Unfair Trade Practice
Other : Unfair claim settlement practices
Other : Unreasonable investigation
Other : Failure to act on claim
Other : Failure to conduct a reasonable investigation based on available information
Other : Failure to maintain proper complaint handling procedures
Other : Misrepresenting the insurance policy provisions to the insured
Other : Misrepresenting Florida statutory provisions to the insured
Other : Misrepresenting facts to the insured
Other : Failure to acknowledge and act promptly upon communications with respect to claims
Other : Denying claims without conducting reasonable investigations based upon available information
* Statutory provision(s) which the insurer allegedly violated.
 
624.155(1)(b)(1) 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.
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)(d) Denying claims without conducting reasonable investigations based upon available information.
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 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).
* Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

A. Coverage A - Dwelling and Coverage B - Other Structures 1. We insure against accidental direct physical loss or damage to the property described in Coverages A and B, unless the loss is excluded in Section - I Exclusions. **** B. Coverage C - Personal Property We insure for accidental direct physical loss to the personal property described in Coverage C caused by any of the following perils, unless the loss is excluded in Section I - Exclusions: . . . 2. Windstorm or Hail ADDITIONAL COVERAGES **** 1. Debris Removal a. We will pay your reasonable expense for the removal of: (1) Debris of covered property if a Peril Insured Against that applies to the damaged property causes the loss; or (2) Ash, dust or particles from a volcanic eruption that has caused direct loss to any covered property. 2. Reasonable Emergency Measures a. We will pay up to the greater of $3,000 or 1% of your Coverage A limit of liability for the reasonable costs incurred by you for necessary measures taken solely to protect covered property from further damage, when the damage or loss is caused by a Peril Insured Against. **** 13. Fungi, Wet or Dry Rot, or Bacteria a. The amount shown in the Schedule above is the most we will pay for costs incurred for: (1) The total of all loss payable under Section I caused by "fungi", wet or dry rot, or bacteria; (2) The cost to remove "fungi", wet or dry rot, or bacteria from property covered under Section I; (3) The cost to tear out and replace any part of the building or other covered property as needed to gain access to the "fungi", wet or dry rot, or bacteria; and (4) The cost of testing of air or property to confirm the absence, presence or level of "fungi", wet or dry rot or bacteria. This applies whether performed prior to, during or after removal, repair, restoration or replacement. The cost of such testing will be provided only to the extent that there is a reason to believe that there is the presence of "fungi”, wet or dry rot, or bacteria. **** Also refer to: Coverage A provision, coverage B provision, coverage C provision, coverage D provision, all additional coverages provisions, all coverages provided by endorsement or rider, the declarations page, loss payment or settlement provision, duties in event of loss policy provision, all terms and conditions of section I of the insurance policy, the insurance policy definitions section, the insurance policy‘s exclusion of coverage provisions, all insurance policy provisions that provide coverage to the insured property, and all policy provisions.
 
* Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.

624.155(1)(a)(1) – violating 626.9541(1)(i) 626.9541(1)(a)(1) -- misrepresenting the terms of an insurance policy. 626.9541(1)(i) -- unfair claim settlement practices. Facts of the case: Truck Insurance Exchange (“TRUCK”) has committed the following in handling the insured’s claim: 1) failure to pay benefits owed; 2) failure to act in due diligence and good faith to resolve claims; 3) placing the financial interest of the insurer before that of the policy holder and claimant; 4) failure to properly train, evaluate, and manage adjusters retained to represent the policies and procedures of TRUCK; 5) looking for ways to delay benefit payments and otherwise “low ball” or “stone wall” claims; 6) looking for ways to deny the insured’s claim; 7) looking for ways to reduce recovery to the insured; 8) failure to perform a reasonable investigation; 9) misrepresenting Florida statutory provisions to its insured; 10) misrepresenting insurance policy provisions to the insured; 11) TRUCK has failed and refused to acknowledge coverage and promptly pay the benefits due and owed to the insured; 12) the reasons for this may be attributed to improper training, supervision, and/or motivation of outside adjusters and claims supervisors to promptly and fairly adjust and pay full benefits available to the insured. The insurer may have failed to adopt proper standards of investigation and adjustment of losses or is otherwise not implementing those standards because a proper investigation and full and prompt payment for the loss is not occurring. In Florida, the work of adjusting insurance claims engages the public trust. TRUCK has breached this duty by its adjustment of the insured’s claim of loss. TRUCK has failed to create and implement adequate guidelines for proper investigation to evaluate claims handling and for training and supervision of employees resulting in violations as set forth above. TRUCK has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insured’s insurance claim for damages. Despite the insured’s timely notification to TRUCK of their insurance claim, TRUCK has failed and refused to acknowledge the covered loss and pay all amounts due and owing to the insured under the policy of insurance. TRUCK has failed to promptly settle the insured’s insurance claim, when the obligation to settle the claim had become reasonably clear, under one portion of the insurance, in order to influence settlements under other portions of the insurance policy coverage. Despite the insured’s pleas otherwise, TRUCK has failed and refused to acknowledge its obligation to tender all insurance proceed monies due and owing the insured or assist the insured in mitigation of the damages. In exchange for a premium paid by the insured, TRUCK issued the subject insurance policy which provided coverage from January 27, 2023, to January 27, 2024, for the insured property for “accidental direct physical loss or damage to the property described in Coverages A and B, unless the loss is excluded in Section - I Exclusions.” As such, the subject all-risk Policy contains coverage for all direct physical losses to the insured property unless the loss is specifically and unambiguously excluded from coverage by the Policy. On or about July 30, 2023, the insured property suffered a windstorm loss, and the insured immediately submitted a claim to TRUCK for property damage, i.e., storm, wind, rain, and/or water intrusion damages throughout the insured property. Hence, the insured suffered a substantial loss regarding the real property and continue to suffer such loss. Having suffered such substantial damage, the insured promptly notified TRUCK of the loss in an effort to mitigate the current damage and prevent the exacerbation of any additional losses. The desired result did not follow. TRUCK since being presented the Insured’s claim has misrepresented policy provisions to avoid paying the insured what they are owed under the policy. Ultimately, TRUCK has failed and refused to properly settle the insured’s claim in good faith. The insured has requested that TRUCK conduct an investigation, admit coverage, and pay damages; TRUCK has failed and refused to do so. In short, TRUCK has failed to handle its insured’s claim in good faith in violation of Fla. Stat. 624.155(1)(b)(1), 624.155(1)(b)(3), and 626.9541(1)(i). Based upon TRUCK’s investigation and property inspection, which confirmed covered damage, TRUCK nevertheless sent correspondence to the insured dated December 5, 2023, (signed by TRUCK’S adjuster, Jimmy Pacheco - Fl Adj. Lic. W643806) and communicated its unequivocal denial of the claim. In regard to insurance contracts, a specific refusal to pay a claim is the breach which triggers the cause of action. Allstate Ins. Co. v. Kaklamanos, 843 So. 2d 885, 892 (Fla. 2003); Donovan v. State Farm Fire and Cas. Co., 574 So. 2d 285, 286 (Fla. 2nd DCA 1991) (finding that a breach of contract takes place at the moment the insurance company refuses to pay a claim). Therefore, TRUCK breached the Policy. Moreover, TRUCK’s argued exclusions and/or limitations to coverage are devoid of anti-concurrent causation language. Thus, “coverage may exist where an insured risk constitutes a concurrent cause of the loss even when it is not the prime or efficient cause.” Sebo v. Am. Home Assurance Co., Inc., 208 So. 3d 694, 699 (Fla. 2016). In addition, under the Policy, any ensuing loss to property not excluded or excepted in this policy is covered. Hence, there are a myriad of coverages under the Policy that would provide coverage for the loss. Nevertheless, TRUCK failed and refused to acknowledge the covered loss and pay all amounts due and owing for the loss. Therefore, TRUCK breached the Policy. Questioning the propriety of TRUCK’s coverage denial, and given the extensive nature of the physical damage, the insured retained a loss consultant, Property Pros Consulting (“PPC”), to perform an investigation and damage evaluation in accordance with industry standards and Florida law. Based on its investigation, PPC concluded that a windstorm on or about July 30, 2023, caused damage throughout the exterior of the insured property (particularly the roof warranting replacement). Moreover, PPC determined that at least $45,818.47 worth of repairs would be required to return the property to its pre-loss condition as a result of the windstorm loss. Nevertheless, TRUCK failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, TRUCK breached the Policy. Thereafter, the insured sent correspondence to TRUCK enclosing the supporting PPC report outlining the cause, scope, and cost of the loss along with other supporting documents and requested TRUCK to reconsider its coverage denial. Nevertheless, TRUCK failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, TRUCK breached the Policy. Questioning the propriety of TRUCK’s continued coverage denial, the insured also retained a consulting licensed contractor, Tom Gannon, with LSC Construction Consultants, LLC (“LSC”), to perform an investigation and damage evaluation in accordance with industry standards and Florida law. Based on his investigation, Mr. Gannon concluded that a windstorm on or about July 30, 2023, caused damage throughout the exterior of the insured property (particularly the roof warranting replacement). Moreover, Mr. Gannon determined that at least $29,750.71 worth of repairs would be required to return the property to its pre-loss condition as a result of the windstorm loss. Nevertheless, TRUCK failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, TRUCK breached the Policy. On December 17, 2024, the insured sent correspondence to TRUCK enclosing their Sworn Statement in Proof of Loss, the supporting PPC & LSC reports outlining the cause, scope, and cost of the loss along with other supporting documents, the Notice of Intent to Initiate Litigation, and requested TRUCK to reconsider its coverage denial. To date, TRUCK has failed and refused to acknowledge the covered loss and pay all amounts due and owing under the Policy. Therefore, TRUCK breached the Policy. As such, TRUCK’s coverage denial is a blatant misrepresentation of the available coverages under the Policy in direct violation of Fla. Stats. 626.9541(1)(a)(1), 626.9541(1)(i)(3)(b), 626.9541(1)(a)(1), and 626.9541(1)(i)(2) and is nothing more than a mere pretext to wrongfully deny and delay this claim. As a result, TRUCK has materially misrepresented the coverages under the subject policy to the insured for the purpose and with the intent of effecting settlement of the insured’s claim on less favorable terms than those provided in, and contemplated by, the subject policy in direct violation of Fla. Stat. § 626.9541(1)(i)(2). Further, TRUCK is in violation of Florida statutes §§ 626.9541(1)(a)(1), 626.9541(1)(i)(3)(b), and 626.9541(1)(a)(1) by misrepresenting pertinent facts and insurance policy provisions relating to coverages at issue; and also in violation of Fla. Stat. 626.9541(1)(i)(3)(d) by denying the insured’s claim without conducting a reasonable investigation based upon available information. In summary, the insured’s loss is clearly covered by the terms of the policy of insurance with TRUCK. However, TRUCK chose to deny coverage for the insured’s loss. Despite clear evidence that the damage was covered and caused by a covered peril, the claim was denied. To date, TRUCK continues to deny the insured and its insured full indemnity for the claim. While TRUCK refuses to honor this claim, a jury in Duval County will likely do what TRUCK has refused; exercise the benefit of doubt in favor of the insured in finding full coverage for this loss. Indeed, the insured will undoubtedly meet the burden of proof at trial, under the TRUCK all-risk policy, to show that, while TRUCK provided insurance coverage, damage occurred to the insured property. See Jones v. Federated Nat'l Ins. Co., 235 So. 3d 936, 942 (Fla. 4th DCA 2018). With the data presented within TRUCK’s investigation, PPC’s investigation, and LSC’s investigations, TRUCK’s burden to demonstrate by the greater weight of the evidence that all the physical damage to the insured property was caused solely by excluded perils under the policy and not in combination with a covered peril has not and cannot be met. See Sebo v. Am. Home Assurance Co., Inc., 208 So. 3d 694 (Fla. 2016). Despite clear indicators of covered damage, TRUCK nevertheless inexplicably denied the insured’s claim. As of today, TRUCK has failed and refused to inform the insured of their rights under the policy of insurance and Florida statutes, has improperly delayed the insured’s claim, has wrongfully denied the insured’s claim, and has failed and refused to adequately indemnify the insured for the loss and defiantly continues to do so. Indeed, from the time of receiving the claim, TRUCK has purposely and maliciously delayed in adjusting the subject claim in an effort to either avoid paying the claim altogether or, at the very least, avoid paying the full extent of the loss. Notably, under Florida law, “[t]he filing of a lawsuit does not extinguish the insurer’s obligations under the policy to adjust and pay the claim.” Tristar Lodging, Inc. V. Arch Specialty Ins. Co., 434 F. Supp. 2d 1286, 1289 (M.D. Fla. 2006). To date, the insured has made a good faith effort to comply with all of the requirements under the subject policy of insurance, and it is only fair that TRUCK do the same. Yet, that is not the case. The insured feel that the insured property is a valuable asset, and, by continuously delaying the proper handling of this claim, TRUCK is putting the insured property at risk. As responsible property owners, the insured purchased insurance to protect the property, paid all of the premiums, and have kept up to date with the responsibilities under the policy. Yet, when the insured needed to rely on the insurance because of this unforeseen loss, TRUCK turned its back and delayed and wrongfully denied coverage that the insured are rightfully owed. Ultimately, TRUCK has failed and refused to properly investigate the loss. The insured has requested that TRUCK admit coverage and pay damages, TRUCK has failed and refused to do so, and continues to refuse to fully indemnify the insured for the loss and pay the amounts necessary to properly repair the insured’s property, despite knowing it is required to do so. In short, TRUCK has failed to handle its insured’s claim in good faith. In Florida, the work of adjusting insurance claims engages the public trust; TRUCK has breached this duty by its insufficient adjustment of the insured’s claim. TRUCK has failed to create and implement adequate guidelines for proper investigation to evaluate claims handling and for training and supervision of employees resulting in statutory violations set forth above. TRUCK has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the insured’s insurance claim for damages. Florida statute § 624.02 defines insurance as a contract whereby one undertakes to indemnify another or pay or allow a 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 their damages to put them back into the position they were prior to loss as quickly as possible. TRUCK breached this duty. The actions taken by TRUCK in the handling / adjustment of the insured’s claim were willful, wanton, and with complete disregard for the rights of its insured and occur with such a frequency as to indicate a general business practice and are in violation of Fla. Stat. 624.155 and 626.9541. TRUCK’S actions amount to but are not limited to the following: 1. Claim delay 2. Wrongful claim denial 3. Unfair trade practice 4. Unfair claim settlement practices 5. Unreasonable investigation 6. Failure to act on claim 7. Failure to conduct a reasonable investigation based on available information 8. Failure to maintain proper complaint handling procedures 9. Misrepresenting the insurance policy provisions to the insured 10. Misrepresenting Florida statutory provisions to the insured 11. Misrepresenting facts to the insured 12. Failure to acknowledge and act promptly upon communications with respect to claims 13. Denying claims without conducting reasonable investigations based upon available information 14. 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. 15. 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. 16. Failing to promptly notify the insured of any additional information necessary for the processing of a claim. 17. Failing to clearly explain the nature of the requested information and the reasons why such information is necessary. 18. Failing to pay undisputed amounts of partial or full benefits owed under first-party property insurance policies within 90 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 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. Therefore, to cure the defects outlined in this civil remedy notice, TRUCK must: (1): Admit full coverage for the insured’s loss; and (2): Tender all insurance monies due and owing to the insured for the loss under the subject Policy. A copy of this form submitted to the FDFS has been emailed and/or uploaded and also printed out and mailed to the following parties providing them notice of the filing of this civil remedy notice: Truck Insurance Exchange PO Box 268994 Oklahoma City, OK 73126 myclaim@farmersinsurance.com
Comments
User Id Date Added Comment
jonathan@woolseymorcom.com 05-28-2025 2025-05-28 - WITHDRAWN
cheryl.perez@farmersinsurance.com 02-03-2025 February 3, 2025 Via E-Mail Woolsey Morcom PLLC 203 Fort Wade Rd Suite 260 Ponte Vedra, FL 32081 Delivered by email to: jonathan@woolseymorcom.com RE: Charles Cain Claim No.: 7006834752-1 Dear Jonathan O’Neil, This correspondence is Truck Insurance Exchange’s (“Truck”) response to the Civil Remedy Notice of Insurer Violation No. 797244 filed on behalf of Complainant Charles Cain on December 17, 2024. Complainant alleges that Truck violated various subsections within Sections 624.155 and 626.9541, Florida Statutes, pertaining to Claim No. 7006834752-1 under an insurance policy issued by Truck to Complainant. Truck welcomes the opportunity to respond to the Notice’s allegations. The Notice fails to comply with the specific notice and information requirements set forth in Section 624.155, Florida Statutes, and Form DFS-10-363. Florida law requires strict compliance with the specific notice and information requirements of section 624.155, Florida Statutes. This notice is invalid due to the failure to include statutorily required information as follows: • The notice includes multiple statutory sections that are not relevant. On the merits, Truck avers it handled Complainant’s claim correctly, fairly, in good faith and with due regard for their interests under Complainant’s policy. A review of our records shows the public adjuster, Property Pros Consulting, reported this loss on November 22, 2023, damage to the Complainant’s property as a result of windstorm on July 30, 2023. Despite Complainant’s over three months delay in reporting this loss, Truck conducted a prompt and thorough investigation into this claim. We enlisted the services of an independent third-party vendor, Hancock Claims Consultants and the inspection was completed as scheduled on November 29, 2023 in the presence of our insured and their public adjuster. Based on this inspection and the photographs of the roof, Truck found damage to the roof and water damage to the interior as a result of wear and tear. We did not observe wind related damage. Because wear and tear is excluded from coverage, Truck denied Complainant’s claim on December 5, 2023. On December 21, 2023 we received an estimate to replace the roof from the public adjuster, Property Pros Consulting, for the amount of $45,818.47. The estimate did not support the presence of covered damage to our insured’s property. As such, Truck responded and provided another copy of the claim outcome letter. On February 20, 2024 we received an agreement with Golden Hammer Roofing signed by the insured November 20, 2023. We acknowledged receipt and provided a copy of the claim outcome letter. On April 17, 2024 we received your letter of representation and sent an initial acknowledgment letter. We subsequently provided the certified policy on May 7, 2024. The only facts that Complainant alleges to support their allegations that Truck violated Florida law and handled Complainant’s claim in bad faith is that Truck’s adjustment of the claim did not result in payment of Complainant’s exorbitant demand. Truck’s policy only covers accidental direct physical loss or damage to the property that is not otherwise excluded, which is further limited by the conditions and coverage limits of the policy. In accordance with these terms, Truck properly adjusted this claim. Accordingly, contrary to Complainant’s apparent contention, Truck’s coverage determination was made in good faith. Truck denies any breach of any statutory or contractual duties in the handling of Complainant’s claim. Your notice alleges the “insured immediately submitted a claim”. We respectfully disagree as noted previously the public adjuster reported the claim over three months after the loss date. In addition, you allege our insured retained Property Pros Consulting in response to our coverage decision when in fact they were retained prior to the claim being reported. Since we have been advised that a lawsuit has been filed on this claim, our defense counsel will discuss the facts and the perceived issues with you further during the course of the litigation. At this time, our position on coverage and this claim remains unchanged. While this response is meant to be comprehensive, Truck’s response is based on the limited information provided in the Notice filed by Complainant. Also, this letter or any act or failure to act on the part of Truck or any agent or representative of Truck should not be construed as a waiver of any rights or defenses, including but not limited to proper notice and service, available to it by contract or at law as all such right and defenses are hereby specially reserved. We trust that this response addresses the allegations raised in the Notice. Please contact me if you have any questions or should you wish to discuss this matter further. Sincerely, Cheryl Perez, Company Employee Adjuster General Claims Adjuster (913) 274-0230 Truck Insurance Exchange
Acknowledgement
* 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.

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DFS-10-363
Rev. 10/14/2008