MCMS Adjuster
MCMS Carrier
Adjustors Page
Become an Adjuster with Mariposa
Mariposa Insurance Services is proud to hire only the best adjusters in the industry. In order to be placed on a claims assignment roster, please update this form each year. We will send you a reminder via email when it is time to update this information. It is not necessary to send a resume. Please contact adjusterhelp@mariposaltd.com if you have questions regarding the completion of this form.

Adjuster Questionnaire Note: All fields are required.

Last Name


Address


Zip Code


Email
First Name


City


Home Phone


Date of Birth


State


Mobile Phone


Have you been employed by Mariposa in the past? Yes No
If you answered yes, please indicate when and where.

During the past 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 such license
held by you ever been suspended or revoked? Yes No
If you answered yes, please explain.

Have you ever been convicted, or had sentence imposed or suspended, or had pronouncement of a sentence suspended, or been pardon for conviction or pleaded guilty or no contest to an information or indictment charging any felony or charging a misdemeanor involving embezzlement, theft, larceny, mail fraud, or charging violation of any corporate securities statute or any insurance law, or have you been the subject of disciplinary proceeding of any federal or state regulatory agency? (Please note that “Yes” does not automatically disqualify consideration for employment.)Yes No
If you answered yes, please provide details and locations, including the county, of the offense.

Has any company been so charged, allegedly as a result of any action or conduct on your part? Yes No
What is the most recent degree you earned?

What is your experience level in years in the following claim areas?

Property/Residential


Liability/ Personal
Property/Commercial


Liability/Commercial Auto

Specialty Insurance(i.e. Aviation, Marine, Agriculture, etc.)

Do you speak more than one language? Yes No
If you answered yes, please list the languages you are fluent in:

What is your driver’s license number and state of registration?

Do you have a current Adjuster License? Yes No
If you answered “yes”, list all applicable states and license numbers:

Do you currently carry Auto Liability Insurance? Yes No
If you answered yes, what is the carrier’s name, policy numbers, expiration date and limits?

Carrier’s Name


Expiration Date
Policy Numbers


Limits

Do you currently carry Errors & Omissions Insurance Yes No
If you answered yes, what is the carrier’s name, policy numbers, expiration date and limits?

Carrier’s Name


Expiration Date
Policy Numbers


Limits

What current adjusting/estimate software are you using?

Do you hold any current certifications? Yes No
If you answered yes, list current certifications:

Please add any additional information that was not covered in the above questions: