Public adjuster
Itemized Statement of Recoveries & Compensation Template
Last updated 2026-08-14
The model act's record retention section requires two separate itemized statements for every transaction: one of the insured's recoveries, and one of all compensation received by the public adjuster, from any source whatsoever, in connection with the loss. Alongside them sits a register of all monies received, deposited, disbursed or withdrawn, including transfers out of any trust account.
The phrase that does the work is 'from any source whatsoever'. It is not a statement of what the insured paid. A referral fee from a restoration contractor, a marketing payment, anything of value connected to this loss belongs on it — which is also why the conduct standards prohibit most of those arrangements outright and require any compensation to be disclosed in writing with its source and amount.
The worked example closes out the Harbour Lane claim: what was recovered, what was charged, what the insured actually received, and one entry that had to be disclosed and was uncomfortable.
Jurisdiction
Written primarily against US first-party property practice. Claim handling is regulated state by state — acknowledgment and response deadlines, prompt-payment requirements, adjuster licensing and unfair claims practices standards all differ — and the policy actually issued governs the claim. Where a page cites a statute, model act or regulation, confirm what applies in the state where the loss occurred. Outside the US, treat the structure as transferable and the legal references as not.
Itemized Statement of Recoveries template
Free Word download, no email required. Or open it in Professional Drafter — it lands in your template library, ready to draft against.
When to use this document
- Closing any engagement — this is the accounting the file is required to contain.
- Whenever the insured asks what they have received and what it cost, which they are entitled to ask at any point.
- Preparing for examination: records are open to the commissioner at all times and retained at least five years after the transaction ends.
Worked example
Fictional scenario: closing statement on the Harbour Lane water loss, claim PC-2026-11482, insured D. Okonjo, settled 26 August 2026. Includes one compensation entry that had to be disclosed and should not have existed.
Matter identification
- Insured:
- Daniel Okonjo.
- Loss:
- water damage, 41 Harbour Lane, [City]. Date of loss 14 July 2026. Final amount of loss $27,410.
- Insurer:
- [Carrier]. Policy HO-4471902, dwelling limit $340,000, expiring 1 March 2027.
- Contract executed by:
- T. Halvorsen, licence PA-118427, signed 5 August 2026.
- Carrier claim representative:
- R. Calloway. Insured's attorney: none instructed.
Statement 1 — the insured's recoveries
Date | Payer | Amount | Covers | Pre/post contract
21 Jul 2026 | [Carrier] | $4,000.00 | Emergency mitigation and drying | PRE
31 Jul 2026 | [Carrier] | $2,200.00 | Initial dwelling payment on $18,340 estimate | PRE
26 Aug 2026 | [Carrier] | $19,110.00 | Balance of agreed dwelling repair | POST
26 Aug 2026 | [Carrier] | $2,100.00 | Contents | POST
- Total recovered:
- $27,410.00
- Recovered before contract date:
- $6,200.00
- Recovered after contract date:
- $21,210.00 — this is the fee base.
The pre/post column is the whole point of the statement. Without it the fee is a number the insured has to take on trust; with it, he can check it in about fifteen seconds. The $6,200 was in his hands before Merrow was engaged and no fee is charged on it, which is what the contract said and what this shows.
Statement 2 — all compensation received, from any source
Date | Source | Amount | Basis | Disclosed in writing?
26 Aug 2026 | D. Okonjo | $2,121.00 | 10% of $21,210 recovered post-contract | Yes — contract 5 Aug 2026
26 Aug 2026 | D. Okonjo | $610.00 | Reimbursed expenses, itemised below | Yes — contract 5 Aug 2026
14 Aug 2026 | Kestrel Restoration LLC | $150.00 | Unsolicited 'referral appreciation' | Yes — disclosed 17 Aug 2026, returned 18 Aug 2026
Total compensation received and retained: $2,731.00
The third line is why this statement says 'from any source whatsoever'. Kestrel is the mitigation contractor Mr Okonjo had already engaged before Merrow was involved; no referral was made by this firm. Kestrel sent $150 unprompted on 14 August under a standing internal practice.
It was disclosed to Mr Okonjo in writing on 17 August with its source and amount, and returned to Kestrel on 18 August with a letter asking that no further payments be sent. It appears on this statement even though it was returned, because a statement of compensation received that omits compensation received is not the record the act requires — and because 'we gave it back' is a much better sentence when the entry is on the statement than when an examiner finds it in a bank register that has no matching line.
A public adjuster may not have a financial interest in any aspect of the claim beyond the contracted fee, and may not receive compensation for referring an insured to a repairer. Retaining the $150 would have breached both.
Expenses reimbursed
Type | Contract estimate | Actual | Approval
Independent moisture mapping and drying assessment | $450 | $450.00 | Within estimate
Certified contents inventory support | $300 | $100.00 | Within estimate
Reproduction of policy and claim file documents | $60 | $60.00 | Within estimate
Total reimbursed: $610.00 against $810 estimated.
The contents inventory came in $200 under because the carrier produced its own contents list on 12 August and only a partial review was needed. Under-runs are shown as well as over-runs: a statement that only surfaces expenses when they exceed estimate teaches the reader that the estimates were never meaningful.
No expense exceeded its contract estimate, so no additional written approval was required. Had one been needed it would appear here with its date, because approval after the fact is not the approval the contract describes.
Funds register, net to insured, and retention
All carrier payments on this claim were issued directly to Mr Okonjo. No claim funds were received, held or disbursed by Merrow Loss Consulting, so no escrow or trust account was used on this matter and the funds register for this transaction is nil.
That is stated positively rather than left blank. A blank register and a register that records no funds passed through are indistinguishable on the page and entirely different facts.
The firm's trust account, where funds are held on other matters, is a non-interest-bearing account at a federally insured institution in the home state, as required.
- Total recovered:
- $27,410.00
- Less fee:
- $2,121.00
- Less approved expenses:
- $610.00
- Net retained by the insured:
- $24,679.00
Net position:
Fee and expenses paid by Mr Okonjo on 28 August 2026, two days after he received the settlement payments.
- Transaction terminated:
- 28 August 2026.
Records retained until at least 28 August 2031, and open to examination by the commissioner at all times.
Section-by-section guide
What each section is for, what a good one contains, and where they typically go wrong.
1.Matter identification
The record must identify the insured, the date, location and amount of the loss, the insurer, and the policy — amount, expiration date and number — along with the adjuster who executed the contract, and the names of the insured's attorney and the carrier's claim representatives where they exist. Capture these once at the head of the statement rather than scattered through the file.
2.Statement 1 — the insured's recoveries
Every payment recovered on the claim, itemized: date, payer, amount, what it was for, and whether it fell before or after the contract date. That last column is what makes the fee calculation checkable, and its absence is what makes fee disputes unresolvable. Show the total.
3.Statement 2 — all compensation received, from any source
Every item of value the adjuster received in connection with this loss, whoever paid it. The fee, obviously. Also any reimbursed expense, and anything received from a third party — a contractor, a vendor, a referral arrangement. Most such arrangements are prohibited by the conduct standards, and the correct response to discovering one is to disclose it in writing with its source and amount, not to leave it off a statement that says 'from any source whatsoever'.
4.Expenses reimbursed
Reimbursable expenses were specified by type with dollar estimates in the contract. Show each actual against its estimate. Where an actual exceeds its estimate, show the insured's prior written approval or explain its absence — additional expenses require approval first, so an unapproved overrun is a finding about the engagement, not a rounding difference.
5.Funds register and net to the insured
Where funds passed through the adjuster's hands, the register records everything received, deposited, disbursed or withdrawn, including transfers out of the trust account. Funds held for an insured go in a non-interest-bearing escrow or trust account at a federally insured institution. Close with the arithmetic the insured actually cares about: recovered, less fee, less approved expenses, equals net received, with dates.
6.Retention
Records are retained at least five years after the termination of the transaction with the insured, and are open to examination by the commissioner at all times. Record the termination date the retention period runs from, because 'five years from the file' is not a date and nobody reconstructs it later.
Common mistakes
The failure modes that show up most often when this document is reviewed later.
Producing one combined statement instead of two
The act requires an itemized statement of the insured's recoveries and a separate itemized statement of all compensation received. They answer different questions and a merged document answers neither cleanly.
Reading 'compensation' as meaning only the fee the insured paid
The words are 'from any source whatsoever'. Anything of value connected to the loss belongs on it, including payments from contractors and vendors — most of which the conduct standards prohibit, which is a reason to surface them, not to omit them.
Omitting an item because it was returned
It was still received. A statement that shows the receipt and the return is a clean record; one that shows neither leaves an unexplained entry in the bank register for someone else to find.
Not marking recoveries as pre- or post-contract
Where the fee runs on post-contract recoveries, that column is the entire basis of the calculation. Without it the insured cannot verify the fee, and a fee that cannot be verified is a fee that gets disputed.
Leaving the funds register blank when no funds were handled
Blank reads as unfinished. Recording that no claim funds passed through the adjuster's hands is a positive fact and takes one line.
Dating the retention period from the file rather than a stated termination date
Five years runs from termination of the transaction. If the termination date is not written down, nobody can compute the retention date later, and the records get destroyed early or kept forever.
Questions
- Does the insured get a copy of these statements?
- The act frames them as records to be maintained and open to the commissioner rather than as documents to be served on the insured. Providing them anyway is the better practice: the insured is entitled to understand what was recovered and what it cost, and a closing statement they can check is the single most effective way to prevent a fee complaint.
- How long do the records have to be kept?
- At least five years after the termination of the transaction with the insured, and open to examination by the commissioner at all times. Your state's adopted period may be longer.
- What if a contractor sends a payment I never asked for?
- Disclose it in writing to the insured with its source and amount, and do not keep it. The conduct standards forbid a financial interest in the claim beyond the contracted fee and forbid compensation for referrals. Record both the receipt and the return.
- Can claim funds be held in an interest-bearing account?
- The model says funds received or held on behalf of an insured go in a NON-interest-bearing escrow or trust account at a federally insured institution in the adjuster's home state or where the loss occurred. The record retention section separately requires a register covering all transactions on any interest-bearing accounts, so the two provisions are read together rather than as a contradiction.
The blank template
Exactly what is in the Word download, so you can see the structure before deciding whether you want it.
Matter identification
Statement 1 — the insured's recoveries
- [Date | Payer | Amount | What it covers | Pre/post contract]
- [Total recovered]
- [Total recovered after the contract date — the fee base]
Statement 2 — all compensation received, from any source
- [Date | Source | Amount | Basis | Disclosed in writing?]
- [Total compensation received]
Expenses reimbursed
Funds register and net to the insured
Retention
Download this template
Free Word download, no email required. Or open it in Professional Drafter — it lands in your template library, ready to draft against.
Sources
- NAIC — Public Adjuster Licensing Model Act (Model 228) §18, Record Retention
- NAIC — Public Adjuster Licensing Model Act (Model 228) §19, Standards of Conduct
- NAIC — Public Adjuster Licensing Model Act (Model 228) §14, Public Adjuster Fees
- NAIC — Public Adjuster Licensing Model Act (Model 228) §15, Contract Between Public Adjuster and Insured
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This page is a documentation aid, not legal advice and not a coverage opinion. Claim-handling requirements vary by state and by policy wording, and a template cannot tell you what your file requires. The worked example describes a fictional loss.