"Non-resident Adjuster Affidavit Form" - Mississippi

Non-resident Adjuster Affidavit Form is a legal document that was released by the Mississippi Department of Insurance - a government authority operating within Mississippi.

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Download "Non-resident Adjuster Affidavit Form" - Mississippi

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AFFIDAVIT
Mississippi Insurance Department
Request to Limit the Scope of Licensure as a Non-Resident Independent Adjuster
I hereby certify that I have submitted to the Mississippi Insurance Department an application for licensure
as a non-resident independent adjuster on the basis of reciprocity with my home state as identified on my
License Application.
I understand that Mississippi offers only two types of independent adjuster licenses, as follows:
1. Property & Casualty including Workers’ Compensation, and
2. Workers’ Compensation Only
I further certify that I am applying for a Non-Resident, Property & Casualty Independent Adjuster license,
which includes Workers’ Compensation.
I understand that the Mississippi Insurance Department requires applicants to be licensed and in good
standing in their home state for the lines of authority requested for the non-resident state.
I acknowledge that the adjuster license issued to me by my home state authorizes me to perform
adjustments for Property & Casualty insurance claims, but does NOT authorize me to perform
adjustments for Workers’ Compensation insurance claims.
I further certify that by signing this affidavit, I am agreeing to voluntarily limit the scope of the Non-
Resident Independent Adjuster license issued to me by the Mississippi Insurance Department to
EXCLUDE the workers’ compensation line of authority.
I further certify that I will NOT adjust workers’ compensation claims in the state of Mississippi and I
acknowledge that if I wish to adjust workers’ compensation claims in the future, I will need to provide
evidence to the Mississippi Insurance Department that I have received a passing grade on the Mississippi
Workers’ Compensation Licensing Examination, or that I have received a license to adjust Workers’
Compensation in my home state.
I understand that adjusting workers’ compensation claims without passing said examination or receiving a
license to do so in my home state is a violation of the Mississippi Insurance Code which could subject me
to monetary fines and/or revocation of my license in Mississippi.
This the ______ day of _________, 20__.
_________________________________
_________________________________
Printed Name of Applicant
Signature of Applicant
So Sworn and Affirmed before me, on this the _______ day of ________, 20__.
_________________________________
Notary Public Signature
My Commission Expires:
AFFIDAVIT
Mississippi Insurance Department
Request to Limit the Scope of Licensure as a Non-Resident Independent Adjuster
I hereby certify that I have submitted to the Mississippi Insurance Department an application for licensure
as a non-resident independent adjuster on the basis of reciprocity with my home state as identified on my
License Application.
I understand that Mississippi offers only two types of independent adjuster licenses, as follows:
1. Property & Casualty including Workers’ Compensation, and
2. Workers’ Compensation Only
I further certify that I am applying for a Non-Resident, Property & Casualty Independent Adjuster license,
which includes Workers’ Compensation.
I understand that the Mississippi Insurance Department requires applicants to be licensed and in good
standing in their home state for the lines of authority requested for the non-resident state.
I acknowledge that the adjuster license issued to me by my home state authorizes me to perform
adjustments for Property & Casualty insurance claims, but does NOT authorize me to perform
adjustments for Workers’ Compensation insurance claims.
I further certify that by signing this affidavit, I am agreeing to voluntarily limit the scope of the Non-
Resident Independent Adjuster license issued to me by the Mississippi Insurance Department to
EXCLUDE the workers’ compensation line of authority.
I further certify that I will NOT adjust workers’ compensation claims in the state of Mississippi and I
acknowledge that if I wish to adjust workers’ compensation claims in the future, I will need to provide
evidence to the Mississippi Insurance Department that I have received a passing grade on the Mississippi
Workers’ Compensation Licensing Examination, or that I have received a license to adjust Workers’
Compensation in my home state.
I understand that adjusting workers’ compensation claims without passing said examination or receiving a
license to do so in my home state is a violation of the Mississippi Insurance Code which could subject me
to monetary fines and/or revocation of my license in Mississippi.
This the ______ day of _________, 20__.
_________________________________
_________________________________
Printed Name of Applicant
Signature of Applicant
So Sworn and Affirmed before me, on this the _______ day of ________, 20__.
_________________________________
Notary Public Signature
My Commission Expires: