1. APPLICANT INFORMATION
______________________________________________________________________________________________
Name Title______________________________________________________________________________________________
Company______________________________________________________________________________________________
Address______________________________________________________________________________________________
City State Zip
______________________________________________________________________________________________
Phone Fax Email Address
______________________________________________________________________________________________
Applicant’s Company Website Address (Company website addresses will be hyperlinked from the WIND Umpire Online Directory)
2. LIST OCCUPATION
_________________________________________________________________________________________________________________
3. PROFESSIONAL LICENSURES
(if any)Space is limited to 8 lines of information in this area.)
___ Insurance Adjuster
License Number/State _______________________________ Year Issued _________ Current? Yes/No
___ Independent Adjuster
License Number/State ______________________________ Year Issued _________ Current? Yes/No
___ Public Adjuster
License Number/State ______________________________ Year Issued ________ Current? Yes/No
___ Attorney
License Number/State _______________________________Year Issued ________ Current? Yes/No
___ Engineer
License Number/State _______________________________ Year Issued ________ Current? Yes/No
___ Insurance Agent/Broker
License Number/State _______________________________ Year Issued _________Current? Yes/No
___ CPA/Accountant
License Number/State _______________________________Year Issued _________Current? Yes/No
___ General Contractor
License Number/State _______________________________Year Issued _________Current? Yes/No
___ Building Contractor
License Number/State _______________________________Year Issued _________Current? Yes/No
___ Mediator
License Number/State _______________________________Year Issued _________Current? Yes/No
___ Other (Specify) ___________ License Number/State _______________________________Year Issued _________Current? Yes/
2014 WIND Umpire Directory
®
Application Form for 2014 Umpire Directory
The Windstorm Insurance Network, Inc. (WIND)® welcomes your application to be included in the 2014 WIND Online Umpire Directory. As part of the agreement to be included in the directory, applicants must adhere to important guidelines as mandated by the Windstorm Insurance Network, Inc.
WIND reserves the right to edit directory submissions for clarity and brevity. Proofs will be faxed before final printing.
4. OTHER RELEVANT INFORMATION RELATING TO ABILITY TO SERVE AS AN UMPIRE
(Space is limited to 8 lines of information in this area.)
5. INDUSTRY EXPERIENCE
(List total years experience and then list individual years experience by profession):
_________ Total Year Experience_________ Insurance Company
_________ Independent Adjuster
_________ Attorney (Plaintiff)
_________ Public Adjuster
_________ Attorney (Defense
_________ CPA/Accountant
_________ Mediator
_________ Engineer
_________ Contractor
_________ Other Occupation
(Must Specify)6. EDUCATIONAL/INDUSTRY EXPERIENCE BACKGROUND (Space is limited to 8 lines of information in this area.)
List ONLY educational and industry certifications, industry training and designations. No other background experience
will be included in the directory. Examples include college degrees, post degrees, designations, certifications (not including
WIND Umpire)
WIND reserves the right to edit directory submissions for clarity and brevity. Proofs will be faxed before final printing.
7. INCLUDE A PHOTO IN DIRECTORY? ____Yes ____No
Black and white, gif, jpg or tiff formats only. Passport type face shots only! No company logos will be accepted in place
of headshot photos. No photocopied photos accepted. Photo MUSt be emailed to [email protected].
8. WIND UMPIRE CERTIFICATION COMPLETED? ____Yes ____No
Date/Location__________________________________________________
(Per guidelines, all applicants must attend and obtain the
WIND Umpire Certification® within two years of application and renew certification every three years thereafter.)
9. WIND UMPIRE DIRECTORY APPLICATIONS TERMS AND CONDITIONS the undersigned applicant states as follows:
(1) the information contained in this form is true and correct;
(2) If selected to serve as an umpire, the applicant will serve in a fair and impartial manner and will make a true, just and conscientious award according to the best of his/her knowledge, skill and judgment;
(3) If selected to serve as an umpire, the applicant agrees to personally view and inspect the subject property if requested by one of the appraisers; (4) the applicant attests that he/she has read and agrees to adhere to WIND Code of Ethics for Umpires in Insurance Disputes® as adopted by the Windstorm Insurance Network, Inc.;
(5) the applicant will obtain the WIND Umpire Certification® within two years of application, and renew certification every three years thereafter as a condition to maintaining a listing in the WIND Umpire Directory®;
(6) the applicant shall submit a certified Florida Department of Law Enforcement (FDLE) (or the state you are licensed)
criminal history results form directly to WIND. Each applicant is responsible for any fees associated with his/her obtaining or submitting this criminal history form. You must apply to the state that you reside and do the majority of your work.
two options to submit criminal history results. Please apply to the state you are licensed:
a) Online. In Florida, visit the FDLE website (www.fdle.state.fl.us) for online reporting results. the online fee is $24 and credit cards payment only are accepted for this option. Please submit results to WIND via email at [email protected].
b) Mail: In Florida, visit the FDLE website (www.fdle.state.fl.us) to download the criminal history form. Mail the completed form and $24 check to: FDLE, Attention: User Services Bureau Criminal History Services, P.O. Box 1489, tallahassee, FL 32302. Results may take up to seven business days. Please note: If you elect to have the results sent back to you, you must email or mail the results to WIND, Attn: Umpire Directory, 2929 Langley Ave, Suite 203, Pensacola, FL 32504 or via email at [email protected].
(7) Each applicant must pay the 2014 annual dues to remain a member in good standing of WIND and separately pay the annual $125 fee for inclusion in the 2014 WIND Online Umpire Directory.
____________________________________________ _____________________________________
____________
Print Name
Signature
Date
10. PAYMENT/MAILING INFORMATION
2014 WIND Online Directory annual listing fee is $125. (2014 annual WIND membership dues are not included, and are a separate $75 fee. Please visit www.windnetwork.com to pay dues online or to download a 2014 membership application/renewal form.
q
AMEX
qDiscover
qMastercard
qVisa
qPayPal
(You must pay online to use the PayPal option)Card # ________________________________________________________ Exp. Date _________ Auth. Code ________
Billing Address _____________________________________________________________________________________________________________ Signature___________________________________________________________________________________________________________________
Mail to: Windstorm Insurance Network, Inc.
2929 Langley Avenue, Suite 203 • Pensacola, FL 32504 • Fax to 850.473.0603 (credit cards only)
11. FOR MORE INFORMATION
Contact the Windstorm Insurance Network, Inc. at 850.473.0601 or fax us at 850.473.0603.
Our email address is [email protected]. For more information, visit www.windnetwork.com.
(last 3 digits on back of MC and VISA, front 4 digits on AMEX)
