Personal Information   First Name Middle Name Last Name Date of Birth Address 1 Address 2 City State Zip Code Email Address Phone 1 Fax Cellular Phone Catastrophe Adjusting Experience Property Adjusting Experience (Years) Liability Adjusting Experience (Years) Auto Adjusting Experience (Years) Commercial Property Adjusting Experience (Years) Business Interruption Claim Experience (Years) Flood Adjusting Experience (Years) Earthquake Adjusting Experience? yesno Licensing Information License Number State Expiration Date Years Lic. in the State Year, month and location of last NFIP Seminar attended For whom did you work? Florida Windpool Certification yesno List all applicable Titles and dates of all applicable training and certifications you have received. (i.e. flood training, Environmental training, AIC, RPA, State Farm Certification, I-Car) What estimating system(s) are you proficient with? (Choose all that apply) Boeckh DDS Simsol Xactimate Accupro ADP-PenPro Mitchell CompEst Other: What estimating system(s) do you currently own or lease? Boeckh DDS Simsol Xactimate Accupro ADP-PenPro Mitchell CompEst Other: Professional References Company Contact Person Address Contact Phone Management Experience Have you ever managed adjusters? yesno If yes, please List companies, locations and dates worked Date Company Contact Person Cat Location Contact Phone Are you fluent in any foreign language? Errors and Omissions Coverage Information Do you carry Errors and Omissions or Professional Liability coverage? yesno Additional Information Do you currently have a valid Drivers License? YesNo Do you have any condition that might limit or restrict you or require accomodation in regards to catastrophe claims handling? yesno If Yes, please explain Have you ever been convicted of a felony? yesno - If Yes, please explain Have you ever been involved in a lawsuit regarding claim handling? yesno - If Yes, please explain Please list anyone you would recommend to be added to our roster Name Address Phone Email By forwarding this information, I affirm that the information submitted is true and correct to the best of my knowledge and I further understand that any misrepresentations herein could result in my discharge as an independent contractor by Mid-America Adjustment Company.