Property
Auto
Casualty
Fire
Date
Social Security Number
Email Address
Last Name
First Name
Date Of Birth
Home Address [Street]
City
State (abbrev)
Zip Code
Phone Numbers:
Home
Alternate
Work
Fax
Cell
Pager
Driver's License #
State
Expiration
Emergency Contact Person
Relationship
Home Phone
Do you have access to a vehicle for travel?
Yes
No
Any Auto accidents in the last 5 years? If yes, how many?
What dates?
Yes Type
Do you hold any valid claims adjusting licenses?
What states?
Type
License #
Adjusting Experience
Residential
Years
Gen Liability
Commercial
Auto Liability
Worker's Comp.
Mobile Home
Other
Collision
Wind/Hail
RV
Body Shop
Any Construction or Auto related experience, type and number of years
Are you NFIP Certified? Yes No Seminar Date:
Dwelling Yes No
Commercial Yes No
Large Loss Yes No
Mobile Home Yes No
Condo (RCBAP) Yes No
For what carriers have you worked?
From year to year [mm/yy]
Management's Name [List all 3]
Manager's Phone [List all 3]
Have you been certified by:
State Farm Yes No
Wind/Hail Yes No
Earthquake Yes No
Flood Yes No
Auto Yes No
Farmers Yes No
Allstate Yes No
AmFam Yes No
Do you own a laptop computer? Yes No
Do you have estimating software? Yes No
What type of software do you have?
Have you used:
Xactimate Yes No
ADP Yes No
Mitchell Yes No
CCC Yes No
Are there any restrictions on your availability for assignments? Yes No
If so, please describe
Are you able to climb a ladder?
Yes No
Date City County
Felony
Misdemeanor
State Nature of offense
Name
Position
Firm/Carrier
Address
Phone Number _____________________________________
Phone Number
