General Info

Required fields in RED      |      Dates must be entered in mm/dd/yy format (e.g. 6/29/11).

Check your Interest as an Adjuster: Daily Claims Adjuster Catastrophic Adjuster

First Name: Adj. Code:
Middle Name: Last Name:
Email: Nick Name:
Alt Phone: Cell Phone:
Fax: Home Phone:
Address: Date Available:
City: Deployed Address:
State: Deployed City:
Zip: Deployed State:
Mailing Address (If Different): Deployed Zip:
Xactimate Address:    
Trade Specialty: Trade Specialty 2:
Trade Specialty 3: Trade Specialty 4:
Trade Specialty 5: Trade Specialty 6:


* Please enter ALL states that you are licensed in.
01. State & License Number:  
02. State & License Number:  
03. State & License Number:  
04. State & License Number:  
05. State & License Number:  
06. State & License Number:  
07. State & License Number:  
08. State & License Number:  
09. State & License Number:  
10. State & License Number:  

Flood Certification: NFIP#: Appointed in FLorida:

Experience Info

Enter certifications, prior carriers, and IAs separated by commas:

Certification Type 1
Certification Type 2
Certification Type 3

Prior Carriers:  Prior IAs:

Primary Adj Type: Secondary Adj Type:
Other Policy Type 1:  Other Policy Type 2:
Other Policy Type 3: Other Policy Type 4:

In order of expertise or extent of experience:

Claim Types * 01. 02. 03. 04. 05.
06. 07. 08. 09. 10.

General Skills:

Estimating Software Used: Xactimate Reflections Pen Pro Power Claims
Software goes in field below; click circle to auto-fill or enter manually below. Xactimate 24 EZ-Bid Accu Bid IntegriClaim
Xactimate 25 Mitchell CCC ADP
Simsol Symbility

Bilingual: Birthdate:
Language(s): Citizen (check for yes)?:   Place of Birth:
Individual / Corporation: Worker's Comp: E & O ?