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Personal Information
First Name
*
Last Name
*
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Cell Phone
Work Phone
*
DOB
Date Format: MM slash DD slash YYYY
Questions for Applicant
Date
*
Date Format: MM slash DD slash YYYY
Are you willing to sign a 1099 Agreement?
Yes
No
Thank you for considering us, we don’t use anyone without a signed 1099 Agreement.
Are you willing to sign a Confidentiality and Non-Disclosure document?
Yes
No
Thank you for considering us, we don’t use anyone without a signed Confidentiality and Non-Disclosure.
How many years have you been an adjuster?
0-3
3-5
5-10
10 or more
We only use adjusters with a minimum of 3 years experience.
What type of claims have you handles in the past?
Property
Casualty
Heavy Equipment & Cargo
Multi-Line
Please list all types of claims that you have worked
Would you like to accept daily claims in the area that you live?
Yes
No
What zip code would you be billing your mileage from?
Are you interested handling CAT Work?
Yes
No
What CAT Events or Named Storm events have you worked in the past
How many claims do you need guaranteed to travel to a CAT area?
0-25
26 – 50
51 – 75
76-100
100+
Are you licensed in any states?
Yes
No
Please list all states and license numbers
What Industry Specific Software are you Proficient with?
Xactimate
Symbility
Simsol
Ultramate
CCC
Other
Other
Do you have your own Work Comp Insurance?
Yes
No
Work Comp Insurance Carrier
Work Comp Insurance Policy Number
Do you have E&O Insurance?
Yes
No
E&O Insurance Carrier Name
E&O Insurance Policy Limits
E&O Insurance Policy Number
Do you participate in any Adjuster Associations?
Yes
No
Please list Adjuster Associations
Upload Your Resume
Drop files here or
Please list past employers and dates worked
Highest level of education achieved
High School graduate
Associates Degree
Bachelor Degree
Masters Degree
Insurance Accreditation - Please list AIC, CPCU, ARM, or other designations
Why should we consider you for part of our team?
List Your References
*
I have read and agree to the
1099
and
Confidentiality Agreement
.
Initials
*
Initials entered will be added on the INDEPENDENT CONTRACTOR AGREEMENT which will be email to you.
Signature
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