This information is required to establish a permanent file on your firm. The primary uses will be: 1) to create a listing; 2) to answer inquiries received from the claims departments of insurance companies and/or self-insurers who request more detailed information.

A complete street address and zip code must be listed. A P.O. Box may be included for mailing purposes.
 
Firm Name
Adjusters Licence Number
(if applicable)
State #
State #
Contact Name
Building Address
Street Address
County
City State Zip
Telephone Day
 Night
Fax Number
Email Address
 		Internet Address (URL)
Mailing Address

P.O.Box City State Zip

Check type of losses handled by your firm. If other than those listed, please advise in space provided
First Party Losses: Third Party Losses
Automobile Physical Damage Automobile
Fire & Allied Lines General Liability
Inland Marine

Bodily Injury
Other:

Property Damage

Personal Injury
Workers' Comp.
Other:
When was the present firm established?
List Adjuster Association Memberships:
List previous claim experience of primary partner or principal prior to organization of firm:
I.1. Name
State Licenced
2. Type of Claim Experience
3. Employment History:
Company
Position
From
To
1.
2.
3.

II. 1. Name
State Licenced
2. Type of Claim Experience
3. Employment History:
Company
Position
From
To
1.
2.
3.

III. 1. Name
State Licenced
2. Type of Claim Experience
3. Employment History:
Company
Position
From
To
1.
2.
3.
 

 

 One listing only per company
INSURANCE COMPANY & SELF-INSURED CLIENTS
(No banks or mortgage companies)		 NAME & COMPLETE ADDRESS OF INDIVIDUAL, BRANCH OFFICE, OR DEPARTMENT TO WHOM A VERIFICATION LETTER MAY BE SENT NO. OF YEARS REP. TYPE OF LOSSES HANDLED

Contact Name

Street Address
City, State,
Zip
1.
2.
3.
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