Catastrophe Adjuster Biographical Questionnaire

Catastrophe Adjuster Biographical Questionnaire

Cunningham Lindsey

(Print or Type)

In connection with the above-named company, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) If answer is “no” or “none,” so state.

Full name (initials not acceptable): Click here to enter name
Have you ever been known by any other names?☐ Yes☐ No

If yes, provide the names: Click here to enter text.

Social Security number: Click here to enter text.
Valid driver’s license number: Click here to enter text.Issuing state: Click here to enter text.
Date of birth: Click here to enter a date.Place of birth: Click here to enter text.
Physical address: Click here to enter text.

P.O. Box: Click here to enter text.

Home phone: Click here to enter text.Work phone: Click here to enter text.

Mobile phone: Click here to enter text.Other phone: Click here to enter text.

Email address: Click here to enter text.

Primary language: Click here to enter text.

Other languages: Click here to enter text.

Do you have a valid passport?☐ Yes☐ No

If yes, provide the following information:

Passport number: Click here to enter text.Expiration date: Click here to enter a date. (please attach a copy)

List your residences for the last ten (10) years starting with your current address:

Date: Click here to enter a date.Address: Click here to enter text.

List employers and adjusting companies worked for in the last ten (10) years starting with the most recent:

Date / Employer/adjusting company name and address / Phone number
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Click here to enter a date. / Click here to enter text. / Click here to enter text. /
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List two (2) professional references:

Name / Company / Title / Phone number
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

Former employer may be contacted?☐ Yes☐ No
Are you or have you ever been a public adjuster? ☐ Yes☐ No

If yes, please furnish details of when and where: Click here to enter text.

Education (please provide dates, names, locations, and degrees):

College: Click here to enter text.

Graduate studies: Click here to enter text.

Others: Click here to enter text.

Software experience:

Software / Years of experience / Date last used
a. Xactimate / Click here to enter text. / Click here to enter a date. /
b. Symbility / Click here to enter text. / Click here to enter a date. /
c. Simsol / Click here to enter text. / Click here to enter a date. /
d. MS Word / Click here to enter text. / Click here to enter a date. /
e. MS Excel / Click here to enter text. / Click here to enter a date. /

Have you worked for Cunningham Lindsey in the past?☐ Yes☐ No

If yes, when and where? Click here to enter text.

If no, did we ask you to work for us?☐ Yes☐ No

Last Catastrophe(s) worked: Click here to enter text.

Date: Click here to enter a date.Company: Click here to enter text.

Please indicate years of experience in the following claim types:

0-50 / Property Dwelling / 0-50 / Construction
0-50 / Property Commercial / 0-50 / Crop Loss
0-50 / Mobile Home / 0-50 / Fine Arts
0-50 / Inland Marine / 0-50 / Fire Investigation
0-50 / Auto Liability / 0-50 / Professional Liability
0-50 / Auto Appraisals / 0-50 / Fidelity
0-50 / General Liability (premises/garage, etc.) / 0-50 / Property – Time Element
0-50 / Product Liability / 0-50 / Wrongful Termination
0-50 / Medical Malpractice / 0-50 / Discrimination
0-50 / Heavy Equipment / 0-50 / Guaranty Fund Losses
0-50 / Boat Physical Damage / 0-50 / Flood/NFIP
0-50 / Motorcycle / 0-50 / Litigation/Mediation
0-50 / Workers’ Compensation / 0-50 / Earthquake
0-50 / Longshoreman/Harbor/Jones Act / 0-50 / HAZMAT
0-50 / Aviation Hull / 0-50 / Underground Storage
0-50 / Aviation Liability / 0-50 / Casualty/Bodily Injury
0-50 / Ocean Marine / 0-50 / Business Income Interruption
0-50 / Animal Mortality / 0-50 / Trucking/Cargo
0-50 / Bond / 0-50 / Estimating Property Damage
0-50 / Environmental

Roof Climbing is required. Do you have the capability to climb: ☐1 story☐2 story

Are you NFIP Certified?☐Yes☐NoIf yes, please check the following boxes which apply to your experience handling NFIP claims:

☐ AL – Commercial, Resident, Mobile Home# Years Experience

☐MH – Mobile Home#Years Experience

☐PC – Property Commercial#Years Experience

☐ PR – Property Residential# Years Experience

☐ RCBAP – Condo Association# Years Experience

California Earthquake effective?☐ Yes☐ NoDate: Click here to enter a date.
What type of claims do you prefer?

☐ Hail☐ Flood☐ Hurricane☐ Inside Claims Handling☐ Mobile Homes ☐ Auto ☐ Other

Would you consider working a desk at the CAT office?☐ Yes☐ No

Do you have any experience working in a CAT office?☐ Yes☐ No When? Click here to enter text. Company: Click here to enter text. Describe duties: Click here to enter text.

Have you ever been in a position which required fidelity bond?☐Yes☐No

If any claims were made on the bond, provide details: Click here to enter text.
Have you ever been denied an individual or position schedule fidelity bond, or had a bond cancelled or revoked? ☐Yes ☐No

If yes, provide details: Click here to enter text.

List any professional, occupational, and vocational licenses issued by any public or governmental licensing agency or regulatory authority which you presently hold or have held in the past:

Type / State / License Number / Expiration Date
Type / State / number / date. /
Type / State / number / date. /
Type / State / number / date. /
Type / State / number / date. /
Type / State / number / date. /
Type / State / number / date. /

During the last ten (10) years, have you ever been refused a professional, occupational, or vocational license by any public or governmental licensing agency or regulatory authority, or has any such license held by you ever been suspended or revoked? ☐Yes ☐No

If yes, provide details: Click here to enter text.

List any insurers in which you control directly or indirectly or own legally or beneficially 10% or more of the outstanding stock (in voting power): Click here to enter text.

If any of the stock is pledged or hypothecated in any way, give details: Click here to enter text.

Have you had any DWI/DUI convictions in the last 7 years?☐Yes☐No

Have you ever been convicted of, plead guilty to, or plead nolo contender (no contest) to a felony or misdemeanor? ☐Yes ☐No

If yes, give details and location (county) of offense: Click here to enter text.

Have you ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any insurer which, while you occupied any such position or capacity with respect to it, became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation, or conservatorship? ☐Yes ☐No
Has the certificate of authority or license to do business of any insurance company of which you were an officer or director or key management person ever been suspended or revoked while you occupied such position? ☐Yes ☐No

If yes, provide details: Click here to enter text.

Please return in a separate email to a copy of your resume, all valid licenses, certifications, and a headshot photo.

You are required to have:

Cell Phone
Computer with Adobe Software to create PDF’s
Scanner
Digital Camera
Internet Access

I hereby certify this is true, accurate, and correct.

Signature / Date / Witness / Date

Email the completed and signed for to:

Or fax it to: 214-488-6766

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