Application Form-Partnership

Questions for Applicant

Date*

Are you willing to sign a 1099 Agreement?*

Thank you for considering us, we don’t use anyone without a signed 1099 Agreement.

Are you willing to sign a Confidentiality and Non-Disclosure document?*

Thank you for considering us, we don’t use anyone without a signed Confidentiality and Non-Disclosure.

How many years have you been an adjuster?*

We only use adjusters with a minimum of 3 years experience.

What type of claims have you handles in the past?*

Please list all types of claims that you have worked

Would you like to accept daily claims in the area that you live?

What zip code would you be billing your mileage from?

Are you interested handling CAT Work?

What CAT Events or Named Storm events have you worked in the past

How many claims do you need guaranteed to travel to a CAT area?

Please list all states and license numbers*

What Industry Specific Software are you Proficient with?*

Do you have your own Work Comp Insurance?

Work Comp Insurance Carrier

Work Comp Insurance Policy Number

Do you have E&O Insurance?

E&O Insurance Carrier Name

E&O Insurance Policy Limits

E&O Insurance Policy Number

Do you participate in any Adjuster Associations?

Please list Adjuster Associations