Adjuster Application

Adjuster Application Form

You may wish to download and complete the Forms listed on this page prior to completing application. This would include the W9, Direct Deposit, Background Check and IA Agreement forms. They can then be uploaded and submitted with the application or you may provide them at a later date.
Full Name*

First NameLast Name
E-mail*
Best Contact Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date Submited

MonthDayYear
Were You Referred to us under our Refer an Adjuster Program?*

YesNo
Referring Adjusters Name*
Software
Xactimate*

YesNo
Xactanalysis*

YesNo
Level of Proficiency - Xactimate*

BeginnerIntermediateExpert
Xactnet Address*
Symbility*

YesNo
Level of Proficiency - Symbility*

BeginnerIntermediateExpert
Mitchell Ultramate*

YesNo
Level of Proficiency - Mitchell Ultramate*

BeginnerIntermediateExpert
FileTrac*

YesNo
About You
Total Years of Experience*
Total Number of Claims Worked Last Three Years*
Do you Own or Work for a company as a W2 wage earner?*

YesNo
Employer Name*
Roster Choices*

Residential PropertyCommercial PropertyFarm and Ranch PropertyFarm and Ranch Equipment/BlanketCampers/Recreational VehiclesHeavy EquipmentAuto AppraiserFile Review
Years of Experience Residential Property*
Years of Experience Commercial Property*
Years of Experience Farm and Ranch Property*
Years of Experience Farm and Ranch Equipment/Blanket*
Years of Experience Campers/Recreational Vehicles*
Years of Experience Heavy Equipment*
Years of Experience Auto Appraiser*
Years of Experience File Reviewer*
NAIIA Member*

YesNo
Are you Bilingual?*

YesNo
If Bilingual, What Language?*
Licensed In:

ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Certifications & Designations

CPCUAINSAICHAAG ResidentialHAAG CommercialHAAG WindRGAINSRPA
Other Certs (if any)
References

Please list Three References that can attest to your claim adjusting work product. These could include insurance company claims examiners or adjusting firm management/claim examiners that you have reported to. Try to list references from three separate companies or I/A firms. Thank you!
Reference #1

First NameLast Name
Company Ref #1
Position/Title Ref #1
Phone Ref #1

Area CodePhone Number
E-mail Ref #1
Reference #2

First NameLast Name
Company Ref #2
Position/Title Ref #2
Phone Ref #2

Area CodePhone Number
E-mail Ref #2
Reference #3

First NameLast Name
Company Ref #3
Position/Title Ref #3
Phone Ref #3

Area CodePhone Number
E-mail Ref #3
Social Media

Please let us know of any social media that you would like us to follow or connect with.
LinkedIn

YesNo
LinkedIn Name
Twitter

YesNo
Twitter Handle
Facebook

YesNo
Facebook Name
Document Uploads

If you have a Background Check that has been completed within the last 5 years it may be uploaded in lieu of the Background Check Authorization Form.
Photo

Upload a File

Cancelof
Resume

Upload a File

Cancelof
W9 Form

Upload a File

Cancelof
Direct Deposit Form

Upload a File

Cancelof
Background Check Authorization Form

Upload a File

Cancelof
Independent Contractor Agreement Form

Upload a File

Cancelof
Adjusting License(s)

Upload a File

Cancelof
Adjuster Referral Form

Upload a File
See Form for our Referral Program to Earn $$ Cancelof
Should be Empty:

Adjuster Application Form

Software

About You

References

Social Media

Document Uploads