Form AID-LI-ADJ-AFF "Arkansas Adjuster Affidavit" - Arkansas

What Is Form AID-LI-ADJ-AFF?

This is a legal form that was released by the Arkansas Insurance Department - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the Arkansas Insurance Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AID-LI-ADJ-AFF by clicking the link below or browse more documents and templates provided by the Arkansas Insurance Department.

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Download Form AID-LI-ADJ-AFF "Arkansas Adjuster Affidavit" - Arkansas

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Form AID-LI-ADJ-AFF (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750; FAX: 501-683-2604
WEBSITE: https://insurance.arkansas.gov/pages/industry-regulation/licensing/
ARKANSAS ADJUSTER AFFIDAVIT
TO BE COMPLETED BY SUPERVISING ADJUSTER, COMPANY REPRESENTATIVE, OR ADJUSTING FIRM
I hereby certify that I have investigated the character and record of the Applicant as to the trustworthiness and
general qualifications; have examined the answers in this Application, and that I endorse said Application for an Adjuster
License. Acting as the supervising adjuster, I will directly supervise and review all claims processing of this individual for 1
full year and I will provide notice to the Arkansas Insurance Department if the applicant fails to remain under my
supervision for 1 full year of adjusting claims. I further certify that the applicant will adjust only those lines of insurance for
which he is licensed, to wit and such adjustment will be carried out under the careful supervision.
Property
Casualty
Workers Compensation
My investigation has consisted of ____________________________________________________________________
_______________________________________________________________________________________________
_______________________________________
Signature of Supervising Adjuster
_______________________________________
Printed Name
______________________________________
Date Signed
Arkansas License Number of Supervision Adjuster _________________
I have one years experience of processing claims and the apprentice program of one years supervised
licensure does not apply to me.
______________________________________
Signature of Applicant
_____________________________________
Date Signed
Form AID-LI-ADJ-AFF (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750; FAX: 501-683-2604
WEBSITE: https://insurance.arkansas.gov/pages/industry-regulation/licensing/
ARKANSAS ADJUSTER AFFIDAVIT
TO BE COMPLETED BY SUPERVISING ADJUSTER, COMPANY REPRESENTATIVE, OR ADJUSTING FIRM
I hereby certify that I have investigated the character and record of the Applicant as to the trustworthiness and
general qualifications; have examined the answers in this Application, and that I endorse said Application for an Adjuster
License. Acting as the supervising adjuster, I will directly supervise and review all claims processing of this individual for 1
full year and I will provide notice to the Arkansas Insurance Department if the applicant fails to remain under my
supervision for 1 full year of adjusting claims. I further certify that the applicant will adjust only those lines of insurance for
which he is licensed, to wit and such adjustment will be carried out under the careful supervision.
Property
Casualty
Workers Compensation
My investigation has consisted of ____________________________________________________________________
_______________________________________________________________________________________________
_______________________________________
Signature of Supervising Adjuster
_______________________________________
Printed Name
______________________________________
Date Signed
Arkansas License Number of Supervision Adjuster _________________
I have one years experience of processing claims and the apprentice program of one years supervised
licensure does not apply to me.
______________________________________
Signature of Applicant
_____________________________________
Date Signed