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Independent Adjuster Personal History

Contact Information

Name *

Street Address *

City *

County *

State *

Zip Code *

Phone *

Email *

Have you ever been convicted of a felony? *

Yes

No

If so, please explain: *

Do you have computer experience? *

Yes

No

If yes, please list: *

Do you own or are you willing to purchase a laptop with access to the internet/email to complete the duties of this position? *

Yes

No

Do you have the applicable adjuster license(s) for the applicable state(s)?

N/A

Yes

No

Education

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

High School

College / Trade / Business School

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

List the crops you are familiar with.

Previous Experience

Previous Crop Adjusting Experience

Do you have previous Crop Adjusting experience? *

Yes

No

Company *

Number of Seasons *

Previous P&C Adjusting Experience

Do you have previous P&C Adjusting experience? *

Yes

No

Company *

Number of Years *

Enter numbers only

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

No

Do you have the ability to accept electronic data (email)? *

Yes

No

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

Yes

No

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

Yes

No

If yes, please explain: *

Can you perform the duties of a crop adjuster? *

Yes

No

Such as, but not limited to climbing bins, walking in fields or working outdoors.

If no, please explain: *

Do you currently have an adjusting contract with any other companies? *

Yes

No

If yes, please list: *

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 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.

Signature *

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