Wufoo

Full Name (as it appears on adjuster license)
Name you go by
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Mobile Phone ### - ### - ####
Alt. Phone ### - ### - ####
In what year did you begin your adjusting career?
How many claims have you handled in the last 12 months?
Please indicate the type(s) of work in which you are interested.
Daily Claims Catastrophe Claims Inside Examiner Field Supervisor General Adjuster (Large Loss) UPP (Contents Specialist)

Please check all that appy
In which STATES do you have an adjuster license?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Please indicate the types of claims you have handled.
Homeowners Condominium Commercial Business Interruption Earthquake Flood Hail / Wind Hurricane Large Loss Liability Tornado
Please list the vendors and carriers that you have worked for in the last three years:
If you have experience as an Inside Examiner, please provide details:
If you have experience as a Field Supervisor of an adjuster team, please provide details:
Which of the following estimating systems have you used in the last five years?
XactAnalysis Xactimate IntegriClaim Powerclaim Simsol MSB CommCentral
If you are currently NFIP certified, please provide your NFIP number.
Please indicate the catagories in which you are NFIP certified.
Residential (Dwelling) Manufactured (Mobile) Small Commercial Large Commercial Condominium
Please indicate any other adjuster certifications that you have received (Ex: CA Earthquake certification).
Please list any foreign languages you speak and your level of fluency.
If you have any limitations that would prevent you from climbing on a roof, please describe.
Has your adjuster license ever been revoked? If YES, please provide details.
Have you been convicted of a crime in the last five years (other than minor traffic offenses)? If YES, please provide details.
Have you ever been convicted of a felony? If YES, please provide details.
If you would like to send us your resume, please attach it here.

Please upload .PDF and .DOC (Adobe PDF and MS Word) files only.
Do Not Fill This Out