Registration for Emergency Adjusters

Registration for Emergency Adjusters
This online form may be used to register emergency adjusters who will represent insurers or adjusting firms in the state of Alabama in the event of a catastrophe. This form is not an application for a permanent adjuster license. Out of the emergency adjuster passes requested, the department will determine a percentage of passes that will allow emergency adjusters into areas restricted by law. These passes will differ in color from regular emergency passes. If the adjuster currently holds an Alabama Resident or Non-Resident Adjuster's License, it is not necessary to complete this form. *Instructions* Complete form by answering ALL questions. If you have completed the entire form and you want to register another emergency adjuster, click the "Register Another Emergency Adjuster" button. This will save the adjuster's information you just entered and then clear the adjuster fields for you to enter another adjuster's information. Once you have finished entering the last adjuster's information, click the "Submit Form" button. You will receive a confirmation page confirming that it was successfully submitted.

Storm Name:

The department will mail passes overnight at the company's expense, mail passes first-class at the department's expense, or they may be picked up at a staging site to be posted on our website (www.aldoi.gov) at time of catastrophe.

Please indicate preference:

Regular Mail

Overnight Mail

Pick Up

Shipping method:

Account #:

Mailing Address (Street):

City, State, Zip Code:

Insurer Information

Name of Insurer:

Physical Address (Street):

City, State, Zip Code:

NAIC #:

Insurer Contact Person:

Telephone:

() -

Fax:

() -

E-Mail Address:

Adjuster Information

Last Name of Adjuster:

First Name, Middle Initial:

Drivers License #, Resident State:

Date of Birth:

/ / (MM/DD/YYYY)

Home Address (Street):

City, State, Zip Code:

Home Phone:

() -

Business Phone:

() -

Cell Phone:

() -

Email Address:

Is Adjuster licensed in resident state?

Yes

If no, provide explanation:

July 05, 2008