NAPIA - Regular Membership Application

National Association of Public Insurance Adjusters

Learn About NAPIA > Regular Membership Application

Instructions:

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Contact NAPIA at the phone number below for payment.

Application For Regular Membership
National Association of Public Insurance Adjusters

21165 Whitfield Place, #105
Potomac Falls, VA 20165
(703) 433-9217
FAX: (703) 433-0369

ANSWER ALL ITEMS FULLY. * denotes a required field

The applicant understands and agrees that the submission of an application for membership in NAPIA by e-mail or facsimile shall be considered and will constitute a signed application. There shall be no requirement for a signed original if the applicant prefers to and does submit an application by e-mail or facsimile.

Name: *
Firm name:
Business Address:
City:
State:
Zip:
Business Phone:

Fax Number:
E-mail: *
Web Site URL:

Residence Address:
City:
State:
Zip:
Residence Phone:

Date of Birth:
Age:
Social Security #:

Please check to which address you wish mail sent:

Residence Business

Number of Members in Firm:

Type of Business: Sole Proprietor Partnership Corporation

Names & Titles of all officers, directors & stockholders (if Corp.) or all partners (if partnership):

Your position & the significant specialty(ies) of your practice.

How long have you been associated with your current firm?

Yrs. in P.A. Profession:

Names & positions of all non-clerical employees of firm
(excluding partners, officers, and stockholders):

When and where were you first licensed as a Public Adjuster?

Are you now licensed as a Public Adjuster? Yes No

If so, list where and provide license number(s):

Are you engaged as a Public Adjuster exclusively on a full-time and professional basis?

Yes No

Are you engaged in any business other than public adjusting? If so, describe:

Are you engaged in any way in building construction or fire damage restoration?
If so, describe:

List business or professional organizations of which your firm is a member:

List business, professional, or other organizations to which you personally belong:

Have you ever been reprimanded or disciplined by any Insurance Department or other
government agency? If answer is yes, furnish full particulars.

Has your Public Adjuster's license ever been suspended
or revoked? If yes, furnish full particulars.

Have you ever adjusted any third party claims? If yes, furnish full particulars.

Does your firm maintain an E & O insurance policy?
Yes No

REFERENCES

Give three business references: (Include complete addresses and phone
numbers to facilitate reference checks).

Give three personal references: (Include complete
addresses and phone numbers to facilitate reference checks).

Recommended by:

Proposed by:

I authorize NAPIA to contact me by fax and e-mail until otherwise notified: Yes No

Today's Date: 5/19/2013

By submitting this form I acknowledge that I have read and agree to abide by the NAPIA Constitution and By-Laws, and the NAPIA "Rules of Professional Conduct and Ethics" adopted and sanctioned, from time to time, by this organization.

NOTE: Individuals, Firms and Corporations who, or which act as public insurance adjusters, and who are qualified and entitled to act in such capacity under the laws of the state in which they are so engaged and who fulfill all the requirements of NAPIA, shall be eligible for membership known as Regular Members. Regular membership shall be in the name of the individuals, the partners of each firm and the officers, directors, and stockholders of each corporation. Member firms must enroll as Regular Members all personnel included in this definition.

All applications for membership must be accompanied by no less than fifty (50%) percent of annual membership dues. Upon approval of the application by NAPIA, the Regular Member is required to pay the remaining balance of annual membership dues, and will not be enrolled in NAPIA until payment is received. A dues credit will be issued to those submitting payment in excess of dues required for the balance of the Association year in which the application is made.

Contributions or gifts to this Association are not deductable as charitable contributions for Federal income tax purposes. However, payments of membership dues are deductible for most members of a trade association under Section 162 of the Internal Revenue Code as an ordinary and necessary business expense.

Learn About NAPIA > Regular Membership Application

Application For Regular Membership National Association of Public Insurance Adjusters

Application For Regular Membership
National Association of Public Insurance Adjusters