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*First name

*Last name

*Firm Name

*Email

*Phone

*Bio

*Business/Firm ADDRESS

*Business/Firm CITY

*Business/Firm STATE

*Business/Firm ZIP CODE

*How many years have you been a licensed PA?

*National Producer Number (NPN)

*IL License #

*Firm's IL License #

*List all states and Public Adjuster license numbers. If none, write N/A.

*What percent of your business is: Commercial?

*What percent of your business is: Residential?

*What percent of your business is: Exterior?

*What percent of your business is: Appraisal?

*Complaints against license?

*Are you affiliated with, or do you own a construction company? If yes, what is the company name?

*How did you hear about CLPAA?

*What are you hoping to gain by joining CLPAA membership?

*Do you have a membership with any other PA Association? If so, which one(s)?

*Do you hold any professional certifications/credentials? (AIC, SPPA, CPPA, etc.)

*Employee Information

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Chicagoland Public Adjusters Association

900 W. North Shore Dr.

#276

Lake Bluff, Illinois

60044

join@clpaa.com