Adjuster form – Tela-Adjuster

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Your name*
First Middle Last Suffix
Cell Phone*
Home Phone
Email Address*
Enter Email Confirm Email
Date of Birth*
Date Format: MM slash DD slash YYYY
How did you hear about Telaclaims?
Above Source (if applicable)
Do you want to be considered for inside Work?
Do you want to be considered for field work?
Have you been a member of the US Armed Forces?*
- Yes
- No

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Language*
Additional Languages Spoken
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*
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?*
If so with which Company?*
What year did your adjusting career begin?
Do you have an Adjuster License?*
- Yes
- No
Home State/Province Issued:*
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*
Date Certficate Expires*
Month
Day
Year

Xactimate Version*
Xactimate Address*
Xactimate Key Code*
Xactanalysis User ID*
Other Estimating Software
Guide Wire Proficient
AS/400 Proficient*
Accenture Claims System Proficient*
MS Office Proficient (Word, Excel, Outlook)*
List other Carrier systems worked on and/or proficient on:

Carrier Certification(s)
Certification Name Expiration Date
Haag Roofing Certificates*
Expiration Date*
Month
Day
Year
Rope And Harness Certification*
IICRC Certifications*
CPCU Designation*
AR e Designation*
AIM Designation*
JD Designation*

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