MontBlanc

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.