Canada Independent Adjuster Application

Contact Information

First Name

Last Name

Address

Phone

Education

Please list name, location, and diploma/degree for each attended.

High School

College / University / Trade / Business School

Were you referred to Rain and Hail Insurance Service by anyone? If so, who referred you?

Previous crop adjusting experience (if any):

Company

Number of Seasons

Summarize all experience or education which you believe qualifies you for adjusting crop losses:

Such as managing or operating a farm, attending an Agricultural College, etc.

Date you can begin to provide your service each crop season:

Date you must end each crop season:

Are you able to accept assignments on short notice?

Yes

Do you have the equipment necessary to perform the duties of an adjuster or are you willing to purchase the necessary equipment?

Yes

Are you willing to accept assignments that require travel away from home?

Yes

Are there times during the season when you would be unable to work?

Yes

If yes, please explain:

Can you perform the duties of a crop adjuster?

Such as, but not limited to climbing bins, walking in fields, working outdoors, driving long distances, etc.

Yes

If no, please explain:

Have you ever been convicted of a criminal offence?

Yes

If yes, please explain:

List the crops you are familiar with.

Crop Damaging Items

Check the crop damaging items you are familiar with:

Insects

Disease

Herbicide

If you selected any of the above, are you familiar with resulting damage to crop for any of them, if yes, list:

Re: Insects, Disease, Herbicide

References

Reference 1

Name

Address

Phone

Reference 2

Name

Address

Phone

Reference 3

Name

Address

Phone

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 the 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 taxes as a self-employed individual.

Signature

Date

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