Independent Adjuster Personal History

Contact Information
Please list name, location, and diploma/degree for each attended.
Previous Experience
Previous Crop Adjusting Experience
Previous P&C Adjusting Experience
Enter numbers only
Such as, but not limited to climbing bins, walking in fields or working outdoors.
Reference 1
Reference 2
Reference 3
Certification and Release

I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said person, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I also understand that any services provided by me would be as an independent contractor, and not as an employee of the Company and would therefore not qualify for unemployment compensation. In addition, I assume all responsibility with respect to the payment of federal/state taxes as a self-employed individual.

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Enter the characters shown in the image.

If you are a California resident, please read our Notice of Collection.