Adjuster Questionnaire

AmerAdjust | Daily and Catestrophic Claims Adjusting
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

In what year was your first deployment as a property adjuster?

How many claims did you personally handle in the last year as a property adjuster?

Please indicate which department you are interested in?

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

Are you NFIP Certified?

NPN number:

If NFIP certified, enter your NFIP number:

If NFIP certified enter your expiration date:

If NFIP certified list the losses you are qualified to handle:

Do you carry any of these specific certifications?
(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

Software in which you are proficient:

XactimateSymbility

Do you have a current XactNet Address:

YesNo

Do you have a current Symbility Address:

YesNo

Supervisor & QC Experience

Have you ever been a Catastrophe Supervisor?

YesNo

If Yes, give brief details below:

Have you ever been a QC File Examiner?

YesNo

If Yes, give brief details below:

Have you ever been or worked for a Public Adjuster?

YesNo

Are you Bilingual?

YesNo

If Yes, list the languages

Do you have any limitations which would prevent you from climbing & inspecting a one or two story
roof?

YesNo

Have you ever had your adjuster’s license suspended or revoked?

YesNo

If Yes, give details below.

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.

I hereby declare that the above information is true and complete and shall form part of my application to AmerAdjust, LLC.

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:

Within the past seven (7) years, have you been convicted of a felony either Federal or State?

YesNo

Within the past seven (7) years, have you been convicted of a DWI or DUI?

YesNo

Within the past seven (7) years, have you been convicted of Domestic Violence?

YesNo

Have you EVER been convicted of any Sex Offense?

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.

I hereby declare that the above information is true and complete and shall form part of my application to AmerAdjust, LLC.

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.

Your name as it appears on your driver’s license:

Driver’s License Number #

State of Issue:

Expiration Date of your Driver’s License:

Auto Liability Insurance Carrier:

Policy Number:

List any DRIVING RESTRICTIONS in the space 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.

I hereby declare that the above information is true and complete and shall form part of my application to AmerAdjust, LLC.