Addendum Form To Adjuster Application
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1INSURANCE LICENSING SECTION
2910 NORTH 44TH STREET, SUITE 210
PHOENIX, ARIZONA 85018-7256
FORM ADJ.ADDENDUM
ADDENDUM TO ADJUSTER APPLICATION
Pursuant to the requirements of Arizona Revised Statutes § 20-312, adjusters must
maintain in this State an office accessible to the public and keep therein the usual and
customary records pertaining to transactions under an adjuster’s license.
Enter below the Arizona business address and telephone number of each location. If a
firm/corporate applicant, also enter the names of licensed adjusters within each office. If
additional space is required, complete and sign additional forms.
FULL NAME OF APPLICANT:
Street Address
LOCATION 1
City
State
Zip Code
Telephone
ADDRESS
Full Name (LAST, FIRST, MIDDLE):
AZ Insurance License #:
LOCATION 1
LICENSED
ADJUSTERS
Street Address
LOCATION 2
City
State
Zip Code
Telephone
ADDRESS
Full Name (LAST, FIRST, MIDDLE):
AZ Insurance License #:
LOCATION 2
LICENSED
ADJUSTERS
Street Address
LOCATION 3
City
State
Zip Code
Telephone
ADDRESS
Full Name (LAST, FIRST, MIDDLE):
AZ Insurance License #:
LOCATION 3
LICENSED
ADJUSTERS
__________________________________________
Full Signature of Applicant
( including FULL first, middle and last names )
Form ADJ.ADDENDUM (Effective 01/98)
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