Adjuster Employment Application
Candidate Position: *     NOTE: All fields marked with * are required!
First Name: *
Middle Name:
Last Name: *
Email:
*
Date of Birth: *
Phone# (Home): *
Phone# (Mobile):   *
Select carrier in order to receive deployment notifications and job opportunities.
Fax:
Address (Line 1): *
Address (Line 2):
City: *
State/Province: *
Zip: *
XACTNET Address: We highly recommend that you provide your XACTNET Address
Education:
School Name is required where a degree is attained.
School Type School Degree Attained
High School
College
Other
References:
Phone and Relationship are required for all references.
Name Phone Relationship
Adjuster Licenses:
*At least one license required.
License# and Expiration Date are required per license.
Enter N/A if not required by state
SelectLicensesInitial License DateExpiration DateLicense#
Alabama
Alaska
Arizona
Arkansas
California
Canada
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Adjuster Certifications:
*Initial Cert Date is required for all selected Certifications.
SelectCertificationInitial Cert DateRecert DateCertification#
AAA TX
Allstate
American Family
ASI
California Earthquake Authority
Citizens of Florida
Citizens of Louisiana
Federated National
HAAG
NFIP (Flood)
Rope and Harness
State Farm
TWIA / TFPA
USAA
Xactimate Level 1
Xactimate Level 2
Xactimate Level 3
Adjuster Experience:
*Please select at least one line of adjusting and include years of experience
SelectLine of Adjusting# Years Experience
Residential Property
Commercial Property
General Liability
Auto Liability
Languages Spoken:
Please select at least one language.




Software Skills:
SelectSkill# Years Experience
Xactimate
Filetrac
Simsol
Adjuster Expertise:
Please select all Loss Types you have expertise with, and enter the # of claims for each line of business.
SelectLoss Type#Residential
CAT Claims
#Commercial
CAT Claims
#Residential
Daily Claims
#Commercial
Daily Claims
Burglary/Theft/Robbery
Dropped Object/Tile
Fire
Flood
Hail
Lightning
Not Otherwise Classified
Roof Leak
Sinkhole
Theft
Vandalism & MM
Vehicle
Water Damage
Water/Plumbing/Other
Water/Slab
Wind Damage
Wind/Water Damage
Windstorm
CAT Address City:
CAT Address State/Province: