EMPLOYMENT APPLICATION
An Equal Employment Opportunity Employer
We consider applicants for employment without regard to race, color, religion, sex, national origin, age or any non-jobrelated disability. Equal access to employment is available to all individuals. Those applicants requiring reasonable
accommodation in connection with the application or interview process should notify Human Resources.
This application will be given every consideration, but its receipt does not imply that the Company will employ the
applicant. This employment application will be used by RENFROE, and all of its affiliated and/or subsidiary
companies. Information provided by the applicant may be shared with the Company’s clients or potential clients.
PERSONAL INFORMATION
Full
Name:
Last
First
Middle
Nickname
Street
City
County
State
Zip Code
City
County
State
Zip Code
Physical
Address:
Mailing
Address:
Street or P.O. Box
Home
Telephone:
Cell
Telephone:
Facsimile
Telephone:
Pager:
E-mail
Address:
Social
Security #:
Are you eligible for legal
employment in the United States?
Do you hold a valid passport?
Yes
Driver’s License #:
No
Yes
Passport#:
Exp Date:
Issuing State:
Exp Date:
No
Emergency
Contacts:
Name
Relationship
Telephone #
Name
Relationship
Telephone #
List any foreign language(s) that you
can speak fluently:
Version 09/10/10
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850  (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
BACKGROUND INFORMATION
Are you currently charged with, under indictment for, or have you ever pled guilty to,
pled nolo contendere to, agreed to deferred adjudication or been convicted of any
felony?
If Yes, please explain:
Are you currently charged with, under indictment for, or have you ever pled guilty to,
pled nolo contendere to, agreed to deferred adjudication or been convicted of any
misdemeanor charge during the past 7 years?
If Yes, please explain:
Are you currently disqualified from handling claims for an insurance company or
independent adjusting firm?
If Yes, please explain:
Are you capable of, with or without accommodation, operating a desktop and/or laptop
computer; obtaining measurements from roofs and living areas; inspecting attics,
basements, crawl spaces, and other claim locations; and carrying/climbing an OSHA
approved ladder which may exceed 50 lbs in weight?
Do you have any current obligations (employment, military, family or otherwise) which
could interfere with your ability to accept immediate deployment and to serve out
assignments for the Company?
If Yes, please explain:
Version 09/10/10
2
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
PREVIOUS WORK HISTORY
FULL-TIME WORK
List in chronological order the name of each company that you worked for on a full-time basis (not project
to project) in the last five (5) years. (Companies that you worked for on a project-basis will be listed
separately.) If you did not work for any company on a full-time basis in the last five years, please
write "NONE" in the first “Company Name” space.
Employment Dates
Start Date - End Date
Company
Name
Company Address
Street, city, state, zip code
Gaps in employment of
more than 4 weeks must
be noted and explained.
Company
Phone #
Supervisor
Must include
area code
Give the name of
person at the
company
who can verify your
employment
Start Date:
End Date:
Start Date:
End Date:
Start Date:
End Date:
Start Date:
End Date:
Start Date:
End Date:
Start Date:
End Date:
Start Date:
End Date:
Please use the table on page 15 if additional space is needed.
Version 09/10/10
3
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
PROJECT WORK
Taking one year at a time, list the name of each company that compensated you for project work either as
an employee (W-2 income) or as an independent contractor (Form 1099) in the last five (5) years. If you
did not perform any work on a project basis in the last five years, please write "NONE" in the first
“Company Name” space.
Year
Company Name
Company Address
Street, city, state, zip code
Company
Phone #
Must include
area code
Name of Person in
Personnel Dept
who can verify
your work dates
Please use the table on page 15 if additional space is needed.
Version 09/10/10
4
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
MILITARY HISTORY
Have you ever served in the U.S. Armed Forces?
Number of years served
Yes
No
What Rank did you attain?
Were you given an honorable discharge?
If No, please explain:
Yes
No
EDUCATION
Schools, Colleges, Trade Schools, etc.
Name of High School,
College, Trade School, etc.
City and State
Last Year
Completed
Degree or
Diploma
Earned
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Major Course of Study
Please use the table on page 15 if additional space is needed.
Version 09/10/10
5
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
REFERENCES
Please give (3) BUSINESS REFERENCES (business people who know you in business)
NAME
Street
ADDRESS
City
State
Zip
PHONE
(Include area
code)
OCCUPATION
Please give (3) PERSONAL REFERENCES (people who know you personally)
NAME
Street
Version 09/10/10
ADDRESS
City
State
Zip
6
PHONE
(Include area
code)
OCCUPATION
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
ADJUSTER INFORMATION
Please read this section of the application in its entirety before beginning. If you see that you will
need more space for the information requested, please refer to the extra tables in the back of this
application.
For any license or certification that you list on this application, you must scan and attach a clear, legible
and valid copy to back it up, or fax a copy to (205) 982-6239. Otherwise, it will not be accepted.
Do not leave any questions unanswered or sections blank. If a section does not apply to you, write “N/A”
or “NONE” in the appropriate space.
LICENSE INFORMATION
Adjuster Licenses:
Are you a licensed insurance adjuster in any state?
Yes
No
If Yes, list all
licenses held below. Please use the table on page 16 if additional space is needed.
LICENSE TYPE
(Auto, All Lines, Ltd. Lines,
Casualty, etc.)
LICENSE CODE
(if on your license)
STATE
LICENSE NUMBER
EXPIRATION DATE
You must provide valid proof of all licenses listed.
Version 09/10/10
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CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
Other Relevant Licenses:
List any other licenses held (contractor, real estate, etc.) that enhance your ability to perform claims
adjusting work. Please use the table on page 16 if additional space is needed.
STATE
TYPE OF
LICENSE HELD
LICENSE
NUMBER
RENEWAL
DATE
EXPIRATION
DATE
# OF YEARS LICENSED
IN THIS STATE
You must provide valid proof of all licenses listed.
CERTIFICATIONS
Insurance Company Certifications:
List only one certification per line, even if they are all for the same Insurance Company. Please
use the table on page 16 if additional space is needed.
NAME OF INSURANCE
COMPANY
CERTIFICATION
TYPE
DATE CERTIFICATION
COMPLETED
NAME OF SPONSORING
COMPANY
You must provide valid proof of all certifications listed.
Version 09/10/10
8
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
Other Relevant Certifications:
List any other current certifications that you have received applicable to Claims Adjusting, such as a
State Wind Pool, NFIP, etc. Please use the table on page 16 if additional space is needed.
NAME OF ISSUING ENTITY
CERTIFICATION
TYPE
DATE CERTIFICATION
COMPLETED
NAME OF SPONSORING
COMPANY
You must provide valid proof of all certifications listed.
OTHER QUALIFICATIONS
Use the space provided to tell us about any special skills and/or qualifications that you possess that are
relevant to adjusting or any other training that you have received that has not already been noted, including
any relevant military training:
Version 09/10/10
9
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
COMPUTER HARDWARE AND SOFTWARE
COMPUTER
Computer Skills:
At what level are your computer skills?
None
Beginner
Intermediate
Advanced
Computer Hardware Requirements:
Are you willing to provide a computer and printer that could be used to write estimates or perform other
Yes
No
business needs with the following minimum system requirements?







Windows XP service pack 2 operating system (or higher)
1 GHz processor (1.5 GHz or better is recommended)
512 MB of RAM (1 GB or better is recommended)
1.5 Gig of free hard drive space available
DVD-ROM drive
SVGA color monitor with resolution set at 1024x768
Internet Service Provider (ISP) with email address
Software:
Please list the names of estimating software with which you are proficient and your level of proficiency.
Name of Software
Version#
______________________________
_________
______________________________
_________
______________________________
_________
______________________________
_________
______________________________
_________
______________________________
_________
Version 09/10/10
Advanced
10
Intermediate
Beginner
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
ADJUSTING EXPERTISE
Property Claims:
Total Years Residential Property _______ Total Years Commercial Property
_______
Total Years Mobile Home Property _______ Total Years Business Interruption
_______
“Day to Day” Property Claims: Property claims handled in a non-catastrophe environment, including
house fires, water damage, lightening damage, etc., and could have included small numbers of various
“CAT coded” claims.
INSTRUCTIONS FOR STAFF ADJUSTERS: List each year of experience working “day-to-day”
property claims, starting with the most recent and working back. Do not omit any information.
Please use the table on page 17 if additional space is needed.
INSTRUCTIONS FOR INDEPENDENT ADJUSTERS: List separately each “day-to-day” claim
assignment that you have worked for each of the last five (5) years, starting with the most recent
and working back. Do not omit any information. Please use the table on page 17 if additional
space is needed.
Year
Worked as:
Staff
Employee
Adjusting
Firm
Employee
Name of
Your
Employer :
Your Position
such as:
Work Location
(City/State):
Name of Insurer
whose claims you
handled:
Manager
Supervisor
Field Adjuster
Inside Adjuster
Residential
Mobile Home
Commercial
Bus. Interruption
Independent
Contractor
Version 09/10/10
List the type(s)
of property
claim(s) handled,
such as:
11
If you handled
any CAT
coded claims,
list the peril(s)
such as:
Hail
Wind
Flood
Sewer Backup
Earthquake
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
Catastrophe Property Claims:
Total Years of ONLY Catastrophe Property Adjusting (Project to Project): _______
Total Years of ONLY Catastrophe Experience handling: Hail ______ Hail to Wood Roofs ______
Flood _______ Wind _______ Sewer Backup _______
List separately each hail, wind, flood or sewer backup project on which you have worked during
the past five (5) years, starting with the most recent and working back. Do not omit any
information. Please use the table on page 17 if additional space is needed.
Year
Worked as:
Staff
Employee
Adjusting
Firm
Employee
Name of
Your
Employer :
Your Position
such as:
Work Location
(City/State):
Manager
Supervisor
Field Adjuster
Inside Adjuster
Name of
Insurer
whose
claims you
handled:
Residential
Mobile Home
Commercial
Bus. Interruption
Independent
Contractor
Version 09/10/10
List the type(s)
of property
claim(s) handled,
such as:
12
List the Peril(s)
handled, such as:
Hail
Wind
Flood
Sewer Backup
*If the event was a
tornado or hurricane,
please note.
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
Property Claims from Unusual/Miscellaneous Perils:
List separately each miscellaneous/unusual catastrophe project such as earthquakes, firestorms,
freeze/winter storm, etc., on which you have worked at any time during your adjusting career,
starting with the most recent and working back. Do not omit any information. Please use the table
on page 17 if additional space is needed.
Year
Worked as:
Staff
Employee
Adjusting
Firm
Employee
Name of
Your
Employer :
Your Position
such as:
Work Location
(City/State):
Manager
Supervisor
Field Adjuster
Inside Adjuster
Name of
Insurer
whose
claims you
handled:
Description of
Miscellaneous
or
Unusual Catastrophe
Event
Residential
Mobile Home
Commercial
Bus. Interruption
Independent
Contractor
Version 09/10/10
List the type(s)
of property
claim(s) handled,
such as:
13
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
AUTO APPRAISING/AUTO ADJUSTING
Total Years Handling Auto Appraisals: ________
Total Years Managing Auto Appraisals: ________
Total Years Adjusting Auto Claims:
________
Total Years Managing Auto Claims:
________
DAY-TO-DAY AUTO APPRAISING AND/OR AUTO ADJUSTING:
(Auto appraisals and/or auto adjustments handled in a non-catastrophe environment.)
INSTRUCTIONS FOR STAFF AUTO APPRAISERS AND/OR AUTO ADJUSTERS: List ALL
of your experience handling DAY-TO-DAY AUTO APPRAISALS AND/OR AUTO ADJUSTMENTS, starting
with the most recent and working back. Do not omit any information. Please use a copy of
this page if more space is needed.
INSTRUCTIONS FOR INDEPENDENT AUTO APPRAISERS AND/OR AUTO ADJUSTERS:
List ALL of the DAY-TO-DAY AUTO APPRAISING AND/OR ADJUSTING ASSIGNMENTS on which you
have worked DURING THE PAST FIVE (5) YEARS, starting with the most recent and working
back. Do not omit any information. Please use a copy of this page if more space is needed.
Year
Worked as:
-Staff
Employee
-Adjusting
Firm
Employee
-Independent
Contractor
Name of
your
Employer:
Position:
-Manager
-Supervisor
-Appraiser
-Field
Adjuster
-Centralized
Environment
Adjuster
Name of Insurer
whose claims
you handled:
Work
location
(City/State)
What type(s)
of auto claims
did you
handle?
-Personal
Auto
-Recreational
Vehicle
-Comm. Auto
-Heavy Equip.
-Long Haul
1
Types of damage
handled:
-Flood
-Hail
-Collision
-Theft
-Vandalism
-Other
OR
-Worked in
Total Loss Unit
AUTO APPRAISING/AUTO ADJUSTING (continued)
CATASTROPHE AUTO APPRAISING/ADJUSTING
List all CATASTROPHE wind, hail, flood, fire, earthquake or other CATASTROPHE AUTO PROJECTS
on which you have worked during the past five (5) years, starting with the most recent and
working back. Do not omit any information. Please use a copy of this page if more space is
needed.
Year
Worked as:
-Staff
Employee
-Adjusting
Firm
Employee
-Independent
Contractor
Name of your
Employer:
Project
Position:
Name of Insurer
whose claims you
handled:
-Manager
-Supervisor
-Appraiser
-Field
Adjuster
-Centralized
Environment
Adjuster
Work location
(City/State)
What type(s)
of auto
claims did
you handle?
-Recreational
Vehicle
-Wind
-Hail
-Flood
-Fire
-Earthquake
-Other
-Comm. Auto
OR
-Heavy
Equip.
-Worked in
Total Loss
Unit
-Personal
Auto
2
Types of
damage
handled:
AUTO LIABILITY
Total Years Working Auto Liability Claims:
_________
Total Years Managing Auto Liability Claims: _________
DAY-TO-DAY AUTO LIABILITY CLAIMS:
(Liability claims handled in a non-catastrophe environment.)
INSTRUCTIONS FOR STAFF AUTO LIABILITY ADJUSTERS: List ALL of your experience
handling DAY-TO-DAY AUTO LIABILITY CLAIMS, starting with the most recent and working back. Do
not omit any information. Please use a copy of this page if more space is needed.
INSTRUCTIONS FOR INDEPENDENT AUTO LIABILITY ADJUSTERS: List all DAY-TO-DAY
on which you have worked DURING THE PAST FIVE (5)
YEARS, starting with the most recent and working back. Do not omit any information. Please
use a copy of this page if more space is needed.
AUTO LIABILITY CLAIM ASSIGNMENTS
Year
Worked as:
-Staff
Employee
-Adjusting
Firm
Employee
Name of your
Employer:
Name of Insurer whose
claims you handled:
Position:
-Manager
-Supervisor
-Field
Adjuster
-Centralized
Environment
Adjuster
Work location
(City/State)
Type(s) of
Auto Liability work
performed, such as:
-PIP
-Bodily Injury
-Claim Litigation
-Property Damage
Liability
-Medical Payments
-Uninsured Motorist
-Underinsured Motorist
-Independent
Contractor
3
CONFIDENTIAL
Other Claims Experience:
Total years working Stock Claims
_______
Total years working Crop Claims
_______
Total years working Wet Marine (physical damage)
_______
Total years working Aircraft (physical damage)
_______
Total years working Automobile (physical damage)
_______
Total years working Liability Claims
_______
Total years working
_______
_____________________
Name of other experience
NOTICE TO ALL APPLICANTS: IT IS IMPORTANT THAT YOU READ THE SECTION BELOW PRIOR
TO SIGNING AND DATING THIS APPLICATION.
The information I am presenting in this application is true and correct to the best of my knowledge, and I
understand that any falsification, misrepresentation or omission is grounds for immediate termination of
employment or refusal to hire.
Applicant’s Printed Name: __________________________________________________________
Applicant’s Signature:
__________________________________________________________
Date this Application is Completed: ___________
Version 09/10/10
14
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
EXTRA TABLES
You do not need to fill out any of the following tables unless you ran out of space in the previous tables.
Employment History:
Employment Dates
Start Date - End Date
Company
Name
Company Address
Street, city, state, zip
code
Gaps in employment of
more than 4 weeks must
be noted and explained.
Company
Phone #
Must include
area code
Supervisor
Give the name of
person at the
company
who can verify
your employment
Type of
Work
Start Date:
End Date:
Project
Full-time
Start Date:
End Date:
Project
Full-time
Start Date:
End Date:
Project
Full-time
Start Date:
End Date:
Project
Full-time
Start Date:
End Date:
Project
Full-time
Start Date:
End Date:
Project
Full-time
Start Date:
End Date:
Project
Full-time
Education:
Name of High School,
College, Trade School, etc.
Version 09/10/10
City and State
Last Year
Completed
Degree or
Diploma
Earned
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
15
Major Course of Study
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
EXTRA TABLES
You do not need to fill out any of the following tables unless you ran out of space in the previous tables.
Licenses:
STATE
TYPE OF
LICENSE HELD
LICENSE
NUMBER
RENEWAL
DATE
EXPIRATION
DATE
# OF YEARS LICENSED
IN THIS STATE
Certifications:
NAME OF ISSUING ENTITY
Version 09/10/10
CERTIFICATION
TYPE
DATE CERTIFICATION
COMPLETED
16
NAME OF SPONSORING
COMPANY
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com
CONFIDENTIAL
EXTRA TABLES
You do not need to fill out any of the following tables unless you ran out of space in the previous tables.
Adjusting Expertise:
Year
Worked as:
Staff
Employee
Adjusting
Firm
Employee
Name of
Your
Employer :
Your Position
such as:
Work Location
(City/State):
Manager
Supervisor
Field Adjuster
Inside Adjuster
Name of
Insurer
whose
claims you
handled:
Residential
Mobile Home
Commercial
Bus. Interruption
Independent
Contractor
Version 09/10/10
List the type(s)
of property
claim(s) handled,
such as:
17
List the Peril(s)
handled, such as:
Hail
Wind
Flood
Sewer Backup
*If the event was a
tornado or hurricane,
please note.
CONFIDENTIAL
E.A. RENFROE & COMPANY, INC.
P.O. BOX 361850 BIRMINGHAM, AL 35236-1850 (205) 982-6230 24 HRS FAX (205) 982-6239 www.earenfroe.com