Adjuster Application Form

AmeriCat enjoys one of the best reputations in the insurance industry today because our adjusters represent our most important asset and standon the front line when it comes to delivering service. If you are interested in becoming a part of the AmeriCat team, we welcome you to apply below.

Personal Information
First Name
Middle Name
Last Name
Date of Birth
Address 1
Address 2
City
State
Zip Code
Email Address
Home Phone
Cell Phone
Pager
Pager PIN
Social Security Number	or
Federal Tax ID Number
Emergency Contact Person
Home Phone
Work Phone
Other Phone

Catastrophe Adjusting Experience
Property Adjusting Experience	years	months
Liability Adjusting Experience	years	months
Auto Adjusting Experience	years	months
Commercial Property Adjusting Experience	years	months
Business Interruption Adjusting Experience	years	months
Flood Adjusting Experience	years	months
Earthquake Adjusting Experience	years	months

Please list your last 10 catastrophes worked
Castastrophe Number 1
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 2
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 3
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 4
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 5
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 6
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 7
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 8
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 9
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled


Castastrophe Number 10
Date	Location

Adjusting Company	Insurance Company/Companies

Types of Claims Handled

Licensing Information
License Number 1
License Number	State

Expiration Date	Years Licensed


License Number 2
License Number	State

Expiration Date	Years Licensed


License Number 3
License Number	State

Expiration Date	Years Licensed

Flood Certificate Number		Recertification Date
Date of last NFIP Seminar		NFIP Seminar Location
Date of last flood worked		Last Flood For Whom
FWIP Certification #		Last FWIP Storm worked
TWIP Certification #		Last TWIP Storm worked

List any other traning or certifications you have received.
What estimating systems are you proficient with?
Which do you currently own or lease
List other software you are proficient with

Management
Do you have Management experience?
If yes, list your last three.

Company 1	Date

Capacity	Storm

Types of files handled


Company 2	Date

Capacity	Storm

Types of files handled


Company 3	Date

Capacity	Storm

Types of files handled

Additional Information
On average how many days after an inspection do you take to complete your paperwork?
Do you have any condition that might limit or restrict you in handling catastrophe claims?
Do you have a current valid drivers license?
State of Issue
License #
Expiration date
Have you ever been convicted of a felony?
If yes, please explain
Have you evern been convicted of DUI
If yes, please explain
Have you ever been involved in a lawsuit regarding claim handling
If yes, please explain

References
Professional 1
Professional 2
Professional 3
Personal 1
Personal 2
Personal 3

Terms and Conditions
I, , hereby declare that the above information is true and accurate to the best of my ability. I understand that AmeriCat may and will rely upon this information to evaluate my skills to include strengths and weaknesses. I further understand that any false or misleading information would be considered grounds to disqualify my application or to terminate any employment or terminate any contractual relationship that might develop as a result of submitting this form as part of my application for consideration by AmeriCat. I further understand that AmeriCat will keep all information obtained in this background check confidential and shall be used solely for the purpose of evaluating this application.
Applicant
Date