Last Name:

Firts name

M.I.:

Mailing address - Street:

City:

State:

Zip:

Home Phone:

Cell Phone

Email:

1. I starte adjusting claims on the year:

2. I have had direct claims experience with the followinf type of claims:
(write the numbre of claims handled for the type of claim

Type of Claims

Property - Personal Lines:

Property - Comercial Lines:

Liability - Personal Lines:

Liability - Commercial Lines:

Flood:

Other:

3. Types of catastrophes that you have direct claims experience whit:
(write the number of claims handled for the type of catastrophe)

Type of Catastophe

Hurricane:

Hail:

Flood:

Earthquake:

Tornado:

Fire:

State:

License #:

Type:

State:

License #:

Type:

State:

License #:

Type:

State:

License #:

Type:

NFIP Certified

Yes

No

If certified, NFIP #:

Aproved to handle

Residential

Condominium

Mobile Home

Small Commercial

Large Commercial

1. Computer Software used:

Xactimate

Symbility

Word

Excel

Other(specify)

2. Are you Bilingual:

Yes

No

Language(s)

3. Your Educational Background (highest level completed):

High Scholl Graduate

Some College

College Graduate

Post Graduate

4. Have you ever been a Staff Adjuster or Supervisor?.

Yes

No

If yes, please answer:

Company:

Dates

What was your authority?

5. Have you ever worked as an "inside" indepenent adjuster for an insurance company?.

Yes

No

If yes, please answer:

Company:

Dates

What was your role?

6. Errors & Omissions Coverage. Do you have a policy in force?.

Yes

No

7. Can you carry, set up and use a ladder to inspect a one or two story roof?.

Yes

No

8. Have you been convicted of crime in the last five (5) years (including traffic violations) or have you ever been convicted of felony?.

Yes

No

If yes, please give details:

9. Have you ever had you adjuster's license suspended or revoked?.

Yes

No

If yes, please give details:

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