Membership Form

TO THE MEMBERSHIP COMMITTEE OF THE DAYTON CLAIM ADJUSTERS ASSOCIATION

DATE _____________________

I hereby make application for membership in the Dayton Claim Adjusters Association, Inc.. Dues are payable at the time of application. Dues - $10.00 General Members/ $25.00 Associate Members.

NAME _________________________________________________________________________

TITLE __________________________________________________________________________

DESCRIPTION OF DUTIES_________________________________________________________

ADDRESS_______________________________________________________________________

BUSINESS ADDRESS ____________________________________________________________

TELEPHONE NUMBER ___________________________________________________________

EMAIL __________________________________________________________________________

COMPANY OR COMPANIES_______________________________________________________

GENERAL MEMBERS:
I hereby certify that I am employed as a Claim Adjuster for the above named insurance company or companies. I have been employed for the past _______ months, the past _______ years. My principal means of livelihood is gained by the adjustment of claims on behalf of the above named company or companies and that I am not available to the general public as a practicing attorney.

Signature _______________________________        Date    _______________________________

ASSOCIATE MEMBERS:
I hereby certify that I am employed in an industry related to the insurance industry by the above named company or companies. I have been employed for the past _______ months, the past _______ years.

Signature _______________________________       Date    _______________________________

We the below subscribed members of the Claim Adjuster Association Inc., hereby recommend this Application for membership in our Association.

Signatures ______________________________         ______________________________

Approved/Rejected by Board of Trustees ________________

By general Membership ________________

Received General Membership Annual Dues _______________