The Pennsylvania Association Of Independent Insurance Adjusters

Pennsylvania Association of
Independent Insurance Adjusters
APPLICATION FOR MEMBERSHIP

Please provide detailed answers to each question.
To avoid delays in handling your application, it is essential that all questions be answered and mailing addresses be given where requested!

Submitted By:	(name under which applicant's business is conducted)
Physical Address:
Mailing Address:	check if same as physical address
Phone Number:
Fax Number:
Email Address:
Web Address:
Type of Organization: Individual Partnership Corporation Other If other, please explain:
Date Established: Place Established: Established by Whom?:
Date of Incorporation or Partnership: Place of Incorporation or Partnership:
Owner, Partners or Officers (please list titles)

Name ALL persons or organizations owning any part of your firm or sharing in its earnings.

Is this applicant or any partner or officer or spouse thereof employed by or the owner of any interest in any insurance company, insurance agency, brokerage office, self-insurer or finance office? Yes No If so, explain in detail:

Do any of the following have an interest in the business of the applicant?
Insurance Company Insurance Agency Brokerage Firm Finance Company Self-Insurer Repair Service Organization Other business or professional entitites concerned with insurance claims? None Explain if any of the above boxes were checked other than "None":
Is Applicant's Main Office or any Branch Office in the same room or suite with any other activity? Yes No If so, explain in detail.
Does this applicant operate any branch or resident adjuster offices? Yes No If so, at what locations in Pennsylvania? (include address, zip code and phone number)

Lines qualified to adjust and years of experience in each:

Does applicant specialize in any of the lines for which qualified? Yes No If so, explain in detail:

Territory in which applicant can render adequate claim service:
List at least five (5) insurance companies serviced. (Please provide the insurance company's name, address, phone number and email address. Also list the names of individuals at those companies who supervise your work. )

Approximately how many companies does applicant represent?
List any members of the Penna. Association of Independent Insurance Adjusters who are acquainted with the applicant.

List any adjuster groups or association of which applicant is a member.

Please attach a copy of your Declaration Sheet/Certificate of Insurance for your E&O Coverage. (If you do not have an electronic version you may send a copy with your membership fee.)
If Corporation, Attested by:
By checking this box 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 application has been accepted. If accepted for membership, I/We agree to conform to the Constitution and Bylaws of the Pennsylvania Association of Independent Insurance Adjusters and its Code of Ethics.