Work For Us

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Email*

D.B.A., INC. LLC

Number of Employees doing business under this name

This is a daily claims handling operation. If you are applying for an outside adjusting position, you must commit to being available in your respective territory and surrounding area on a daily basis. We handle multiple companies with varying degrees of complexity and you must be willing to handle all assignments sent to you.

Home Telephone*

Business Telephone

Cellular Phone

Are you 18 years of age or older?

Yes

If hired, Federal Law requires that you furnish documentation establishing your identity and eligibility to work in the United States:

Do you have United Sates citizenship or authorization from the Immigration & Naturalization Service to work in the U.S.?

Yes

Have you ever been convicted, pled guilty, nolo contendere (no contest), or recived deferred adjudication for violation of any law other than minor traffic violations?

Yes

If yes, please explain:

Are you willing to work holidays and weekends if necessary?

Yes

Please list your last two positions starting with present or recent employer. Complete even if resume provided.

Company 1:

Company Name

Address

Street Address City State ZIP Code

Phone

Dates Employed (Month & Year)

Salary Starting & Ending

Job Title and Description of Duties:

Reason for Leaving:

Company 2:

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed (Month & Year)

Salary Starting & Ending

Job Title and Description of Duties

Reason for leaving

May we contact the above listed employers?

Yes

If not, please indicate the employers you do not wish us to contact:

Education

High School

Name and Location of School

Course of study

Years completed

Did you graduate?

or diploma

from/to

College

Name and Location of School

Course of study

Years completed

Did you graduate?

or diploma

from/to

Technical / Trade Schoo

Name and Location of School

Course of study

Years completed

Did you graduate?

or diploma

from/to

Other

Name and Location of School

Course of study

Years completed

Did you graduate?

or diploma

from/to

Please list languages, other than English, you speak fluently:

Professional licenses or designations you currently hold:

Summarize special skills and qualifications acquired from employment or other experience.

Typing WPM:

Skills

PC Operating Systems

MS Word

MS Excel

PC Operating Systems

Adobe Acrobat

Xactimate

Other

Please list other software you have experience with:

This section for Adjuster Applicants Only

Have you had any building construction or carpentry experience?

Yes

If yes, in what capacity?

Do you presently have a valid adjuster license?

Yes

Do you presently have a valid adjuster license?

How long have you been licensed?

Licensed State?

Adjuster License #:

Date of Expiration:

Please select the years of experience you have in each item listed below:

Boat Physical Damage

Earthquake

Boat Physical Damage

Flood

Fire

Inland/Ocean Marine

General Liability

Fine Arts

Environmental

Hazardous Materials

Mobile Home

Casualty

Property: Commercial

Dwelling

ALE

Liability

Construction Defects

Consent

I hereby certify my answers to all questions on this application are true and complete.

I understand that any falsified or misrepresented statements on this application shall disqualify me from the hiring process or if hired, will be grounds for dismissal. I authorize Cross Claims Services, Inc.(CCSI), to investigate and verify all statements and information provided. I hereby release from liability CCSI and its representatives for seeking, gathering, and using such information and all other persons, corporations, and organizations from furnishing such information. I understand CCSI may require a drug screen, background check, and credit report as part of their hiring procedure. If hired, I further agree to obey the policies and procedures of CCSI.

This field is for validation purposes and should be left unchanged.

Accurate, Efficient,

& Deligent

If hired, Federal Law requires that you furnish documentation establishing your identity and eligibility to work in the United States:

Please list your last two positions starting with present or recent employer. Complete even if resume provided.

Education

Summarize special skills and qualifications acquired from employment or other experience.

This section for Adjuster Applicants Only

Contact Information