Adjuster Registration

Please complete the form below, in its entirety, and we will send you an email when approved.

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	Currently Available for Deployment: First Name Middle Initial Last Name Nick Name Any Prior Names Date of Birth Soc. Security No. (Home Address) Line 1 Line 2 City State ZIP Country (Mailing Address (if different)) Line 1 Line 2 City State ZIP Country Employer Tax ID No (if applicable) Home Telephone Office Telephone Fax Cell Email Address Eligible for legal employment in the United States? Driving License No Issuing State Exp Date Any vehicular accidents or moving violations in the past 3 years? (If yes, please provide details) (Emergency contact) Name Relationship Telephone Number of years adjusting property claims: Number of years handling:		Yes   No (MM/DD/YYYY) (XXX-XX-XXXX) Yes   No (MM/DD/YYYY) Yes   No Wind:    Hail:    Tornado:    Fire: Hurricane:    Earthquake:    Flood: Residential:    Condo:    Mobile Home: Small Commercial:    Large Commercial:
	Licenses Held
	License Type Code State License No Expiration Date 1 (MM/DD/YYYY) 2 (MM/DD/YYYY) 3 (MM/DD/YYYY) 4 (MM/DD/YYYY)
	Have you previously had your adjuster license suspended or revoked for any reason? (if Yes, please explain with details) Certifications: NFIP NFIP Certification No		Yes   No Yes   No
	Other certifications
	Cert. Type Date of Cert Sponsoring Co 1 (MM/DD/YYYY) 2 (MM/DD/YYYY) 3 (MM/DD/YYYY)
	Professional Designations
	CPCU RPA AIC Other
	Employment History (past 5 years)
	Employment Dates Co Name Address Telephone Supervisor 1 2 3
	Educational Background
	H.S./College/University City/State Yrs. Attended Degree Earned Major 1 2 3
	Military Service
	Branch # Yrs. Served Rank Attained Honorable Discharge (If no, please explain)
	Professional References (3)
	Name Address Telephone Occupation 1 2 3
	Previous CAT Deployments
	Date CAT Employer Tele. Supervisor/Manager 1 (MM/DD/YYYY) 2 (MM/DD/YYYY) 3 (MM/DD/YYYY)
	Any experience as a CAT manager/supervisor? Are you Proficient in Xactimate? Do you have an Xactimate subscription currently? XactNet address: Have you had any training on Xactanalysis, the file management program by Xactware? Do you own a ladder, laptop computer, cell phone and all the other necessary equipment required for property adjusting assignments? Do you agree to submit to a pre-employment drug screen, criminal background check, and motor vehicle records check? Do you possess the ability to climb and lift up to 50 lbs.? Do you own/operate a dependable, professionally presentable motor vehicle covered by an automobile liability insurance policy with minimum limits of $100,000/300,000/100,000? Do you have a policy of Error & Omissions insurance currently in force? Comments: Date: Signature: Upload Photo: Upload Resume:		Yes   No Yes   No Yes   No Yes   No Yes   No Yes   No Yes   No Yes   No Yes   No (MM/DD/YYYY)