CLAIMS ADJUSTER APPLICATION
Company
Last Name
First Name
Physical Address
City

County/Province 
Country

State 

Zip Code 

 -
Is your mailing address the same as your physical address as listed above? Yes No If No, please provide below.
Mailing Address
City

County/Province 
Country

State 

Zip Code 

 -
Date of Birth Tax ID
Home Phone Business Phone
Fax Cell/Pager
E-Mail Address Website
Auto Insurance Carrier

Policy # 
E&O Insurance?

YES

NO

Policy #  
Have you ever been convicted of a crime? Yes No (If Yes, provide explanation below)
Do you have problems with substance abuse? Yes No (If Yes, provide explanation below)
Ever dismissed because of your work conduct? Yes No (If Yes, provide explanation below)
Are you a US Citizen? Yes No (If No, provide work visa number below)
Do you currently hold a professional license? Yes No Type
How did you hear about us?  
 
 
LICENSES State
License Number
Expiration
EDUCATION High School Yes No
College Yes No
Vocational Yes No
Special Training Yes No Type
TECHNOLOGY Do you currently own or have access to the following?
Computer System Yes No
Internet Access Yes No
Digital Camera Yes No
Are you prepared to complete and deliver assignments in a paperless environment?
Yes No
REFERENCES List (3) professional references you have known for at least (2) years:
 

NAME COMPANY PHONE
TERRITORY Primary State Covered:
Secondary State Covered:
Base Location Zip Code: -
Radius Covered from Base Location: miles
Date Available to Start
COMMENTS
ACCEPTANCE

By submitting this electronic application,  I certify that the facts contained herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained here and the references and companies listed above to give you and all information concerning my previous experience and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I agree that no representative of the above noted company has the authority to enter into any agreement for contract for any specified period of time, or to make any agreement contrary to the forgoing, unless it is in writing and then signed by an authorized company representative.