California Association of Independent Insurance Adjusters, Inc.

APPLICATION FOR MEMBERSHIP - Page 1
(Please type detailed answers to each question in this application)

Submitted By:   email address:
Office Address:  Phone #:
City: State: Zip:   Fax #: 

1. Type of Organization? :
2. Date and Place of Incorporation (if incorporated):
3. Date and Place Business Established and by Whom? :
4. State License #:     IRS Employer #:
5. Ownership Information:

Owner, Partners, or Officers Ownership
Percentage		 Lines Qualified to Adjust

6. Name any OTHER Persons or Organizations Owning Any Part of You Firm or Sharing in its Earnings:

7. Adjusting Employees

Adjusting Employees Years
Experience		 Lines Qualified to Adjust

8. Does this applicant operate any other branches? If so, at what locations?

Branch Office Street Address, City and State Phone # Fax # Branch Office Manager

9. Check the following headings and the lines of insurance in which this applicant is qualified to act as adjuster.
Auto   Casualty   Fire   Inland Marine   W.C.   Other

10. Does this applicant specialize in any of the above lines?
If so, Please explain
11. Is this applicant qualified to render other services related to claims work?
If so, Please explain
12. Territory in which this applicant can render adequate claim service:
13. List any members of the California Association of Independent Insurance Adjusters who are acquainted with this applicant:
14. Is this applicant a member of the National Association of Independent Insurance Adjusters (NAIIA), a local adjusters' association or professional organization?
If so, give full name of the association and name and address of secretary
15. List alphabetically a representative number of insurance companies for which adjustments are made. Include two different companies for each major line serviced as shown in the answer to Question 9. (Please show full name and full address of company, full name of company's claims supervisor, number of years applicant has represented the company, and line or lines for which adjustments are made. This information will NOT be released to the general membership or public.

Company

 Address Claims Examiner Years Rep'd Lines Adjusted

16. Personal References

Name Address Phone#


I/we certify that all statements herein or made a part hereof, are true and correct. I/we agree that any falsification may be the basis for rejection by the Association or termination of membership if the applicant has been accepted.

If accepted for membership I/we agree to conform with the Constitution and By-Laws of the California Association of Independent Insurance Adjusters, Code of Ethics of the Association and the Statement of Principles on Respective Rights and Duties of Lawyers and Laymen in the Business of Adjusting Insurance Claims.

Date   Attested by (Name, Title)