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Date Format: MM slash DD slash YYYY
How did you hear about Telaclaims?
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Do you want to be considered for inside Work?
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Do you want to be considered for field work?
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Yes
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Have you been a member of the US Armed Forces?
*
Yes
No
Address
*
Street Address
Address Line 2
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Virgin Islands, U.S.
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Country
Primary Language
*
English
Spanish
French
Chinese
Japanese
Portuguese
Arabic
Hindi-Urdu
Bengali
Italian
German
Russian
Swedish
Polish
Persian
Malaysian
Turkish
Dutch
Swahili
Tamil
Other
Additional Languages Spoken
English
Spanish
French
Chinese
Japanese
Portuguese
Arabic
Hindi-Urdu
Bengali
Italian
German
Russian
Swedish
Polish
Persian
Malaysian
Turkish
Dutch
Swahili
Tamil
Other
To select multiple languages please hold down the CRTL key (CMD key on a Apple) as you select the additional languages
Other Additional Languages Spoken
Your Adjuster Level
*
None
Jr. Adjuster
Adjuster
Sr. Adjuster
General Adjuster
Sr. General Adjuster
Executive General Adjuster
Other
Describe your adjuster level
Line of Business
*
None
Property
Casualty
Auto
Liability
Workers Comp
Third Party Liablity
Crop
Marine
Tort
Directors and Officers
Errors and Ommissions
Environmental
Cyber
All Lines
Other
Describe your other line of business
Approximate # of Homeowners Property Claims handled:
Approximate # of Commercial Claims handled:
Approximate # of Auto Claims handled:
Appraisal/Umpire Work Claims handled:
Have you ever worked as a carrier adjuster?
*
Yes
No
If so with which Company?
*
What year did your adjusting career begin?
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
Do you have an Adjuster License?
*
Yes
No
Home State/Province Issued:
*
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
CONNECTICUT
DELAWARE
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
INDIANA
KENTUCKY
LOUISIANA
MAINE
MICHIGAN
MINNESOTA
MISSISSIPPI
MONTANA
NEVADA
NEW HAMPSHIRE
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTHERN MARIANA ISLANDS
OKLAHOMA
OREGON
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
TEXAS
U.S. VIRGIN ISLANDS
UTAH
VERMONT
WASHINGTON
WEST VIRGINIA
WYOMING
QUEBEC
ONTARIO
BRITISH COLUMBIA
ALBERTA
NOVA SCOTIA
MANITOBA
NEWFOUNDLAND AND LABRADOR
PRINCE EDWARD ISLAND
SASKATCHEWAN
NEW BRUNSWICK
NORTHWEST TERRITORIES
NUNAVUT
YUKON
Adjuster License Number
*
Date Issued:
*
Month
Day
Year
Expiration Date:
*
Month
Day
Year
Other States Non Resident License
NFIP License
Yes
No
NFIP License Number
*
NFIP License Expires
*
Month
Day
Year
California EC
*
Yes
No
Date Certficate Expires
*
Month
Day
Year
Xactimate Version
*
Xactimate Address
*
Xactimate Key Code
*
Xactanalysis User ID
*
Other Estimating Software
Guide Wire Proficient
Yes
No
AS/400 Proficient
*
Yes
No
Accenture Claims System Proficient
*
Yes
No
MS Office Proficient (Word, Excel, Outlook)
*
Yes
No
List other Carrier systems worked on and/or proficient on:
Carrier Certification(s)
Certification Name
Expiration Date
Haag Roofing Certificates
*
Yes
No
Expiration Date
*
Month
Day
Year
Rope And Harness Certification
*
Yes
No
IICRC Certifications
*
Yes
No
CPCU Designation
*
Yes
No
Partial
AR e Designation
*
Yes
No
Partial
AIM Designation
*
Yes
No
Partial
JD Designation
*
Yes
No
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