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Contact  Information
Emergency Contact
Physical Address
Mailing Address
Capabilities & Experience
Types of Claims worked:
Estimating Platform Experience
How many estimates have you written in each platform?

What roof pitch are you able to safely climb? **Please select all that apply. 
Additional Certifications
Please enter additional certifications you have received. 
Please attach a copy of your W9. If you do not have one completed please follow this link to complete one for upload:

Coverage Territory 
You must list the specific state and counties in which you are willing to accept assignments. You will only be assigned claims in the area you select to work in. 
Mileage is not paid on any claim assignment.
Please enter in the following format: "County, State; County, State"
Please enter
Please list 
State Adjuster Licenses

Select all of the states you are licensed in.