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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 complete the form below.

Please note: This form is only supported by Internet Explorer and Firefox browsers.

Adjuster Questionnaire : Step 1 of 4

To remain on the claims assignment roster, you will need to update this form yearly. We will send you a reminder via email when it is time to update this information.

Your Information

*indicates a required field

Email: (email@domain.com)

First Name:

Last Name:

Date of Birth: (xx/xx/xxxx)

Address:

City:

State: (xx)

ZIP: (xxxxx)

Business Telephone: ( (xxx) xxx-xxxx )

Mobile Telelphone: ( (xxx) xxx-xxxx )

Adjuster Questionnaire : Step 2 of 4

To remain on the claims assignment roster, you will need to update this form yearly. We will send you a reminder via email when it is time to update this information.

Your History

*indicates a required field

Have you been employed by Mariposa in the past?

Yes.
No.

Please Indicate When:

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.

Please note: 255 characters maximum in this field

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.

Please note: 255 characters maximum in this field

Has any company been so charged, allegedly as a result of any action or conduct on your part?

Yes.
No.

Please note: 255 characters maximum in this field

mariposa insurance services ltd.

Become an Adjuster with Mariposa

Adjuster Questionnaire : Step 1 of 4

Your Information

Adjuster Questionnaire : Step 2 of 4

Your History

Adjuster Questionnaire : Step 3 of 4

Your Education

Adjuster Questionnaire : Step 4 of 4

Additional Information