Adjuster Questionnaire

Last Name
First Name
Middle Initial

Name you go by
SSN
Date of Birth

Home Address
City
State
ZIP

Home Phone
Cell Phone
Cell Phone Carrier

Email Address

Emergency Contact Name
Relationship
Phone

Field AdjusterDesk AdjusterFile Reviewer

List all of your residences outside the current county in which you NOW reside that you have lived in during
the past seven years
City State From to

Types of claims you have had direct claims experience with.

(Check all that apply AND enter the number of years’ experience you have for each that you check.)
Type of Claims Yes # Years Type of Claims Yes # Years
Property – Personal Lines Business Interruption
Property – Commercial Lines Flood

Types of catastrophes that you have had direct claims experience with:

(Check all that apply AND enter the number of years’ experience you have for each that you check.)
Type of Catastrophes Yes # Years Type of Catastrophes Yes # Years
Flood Earthquake
Hail Fire
Hurricane Liability Cat
Tornado Other First Party Cats

List the CURRENT (Valid)
Adjuster Licenses you have at this time.
State License Number Expiration Date
State License Number Expiration Date

Adjuster Certifications
ResidentialCondominiumMobile HomeSmall CommercialLarge Commercial

(If yes please enter the date of certification)
USAA
LA Citizens
Tower Hill
TWIA
Earthquake
Rope & Harness
Haag Certified (Roof) Commercial
Residential

Additional Certifications
Company Type Date of Certification Score (if applicable)

Estimating Software
XactimateSymbility
YesNo
YesNo

Supervisor & QC Experience
YesNo

YesNo

YesNo
YesNo

YesNo
YesNo

I certify that the information contained in this questionnaire is true and complete to the best of my knowledge and
understand that falsified statements on this questionnaire shall be grounds for dismissal and termination of
any contract with AmerAdjust LLC Adjusting Services.

Information to be disclosed:

Felony convictions either State or Federal, felony convictions involving dishonesty or breach of trust, embezzlement,
fraud, perjury, tax fraud, misdemeanor convictions for assault and battery, convictions for driving while
intoxicated or under the influence of drugs or other substances, which have occurred within seven (7)
years of the date you submit this form. The information will be disclosed for the following purposes:
Investigation into criminal background for purposes of engaging the undersigned individual as an Independent
Contractor. I understand that the information described above may be re-disclosed and no longer protected
by federal and state privacy regulations. I further understand that I may revoke this authorization in
writing at any time by sending or faxing a written notice to the disclosing party above. This written
revocation must state my intent to revoke this authorization. A facsimile, copy, or photocopy of this
authorization shall be as valid as the original.

Convictions:

YesNo
YesNo
YesNo
YesNo

I hereby affirm that the information set forth above is true and correct. I understand that if any of the information given
above is not true and correct, then I have misrepresented information to AmerAdjust LLC and am subject
to immediate dismissal from any catastrophe site. I further understand that, due to any misrepresentations
made herein, AmerAdjust LLC may be penalized for any false statements above. Should the information given
herein be incorrect, I affirm I will reimburse AmerAdjust LLC for any and all penalties. I further understand
that this information contained herein shall be held in strictest confidence by AmerAdjust LLC, its agents,
employees and/or servants. I have freely and voluntarily given the information above for the purposes
of becoming an independent contractor to be used in the capacity of adjusting insurance claims for AmerAdjust
LLC and its clients or for any other capacity in which AmerAdjust LLC might use my services. By signing
this form, I agree that AmerAdjust LLC may conduct an in-depth background check at any time within one
year from the date below.

Driver’s License & Auto Liability Insurance

All AmerAdjust LLC Adjusters must have a valid driver’s license and auto liability insurance. Please complete
the requested information below.

I certify that I hold a valid Driver’s License and that the above information is correct, and the insurance is in force.
I understand I must have auto liability insurance coverage in force and agree to advise AmerAdjust, in
writing, of any changes in the above information.