Member Application

Applicant Information

* First

* Last

* Home Address

* City

* State

* Zip

* Phone

* Email

* Date of Birth

Employment

* Present Employer

* Immediate Supervisor

* Address

* City

* State

* Zip Code

* Phone

* Nature of Business

* Date Hired Please list month and year

* Positions & Duties

Previous Employment

(Employer #1)

Employer

Address

City

State

Zip Code

Positions & Duties

Dates of Employment Please list start/end year and month

(Employer #2)

Employer

Address

City

State

Zip Code

Positions & Duties

Dates of Employment Please list start/end year and month

Background

* Have you ever been convicted of a crime (other than a minor traffic offense)?

Yes
No

If yes, please provide details

* Have you ever been sued by an insurance company?

Yes
No

If yes, please provide Case No. and State

Educational Background

* High School

* College

* College Degree

* Graduate School

* Graduate School Degree

* Professional Training Schools

* Professional Organizations

License Information

* Has any state license ever been revoked, suspended, or any investigation concerning any license?

If yes, please explain

This section is for applicants other than insurance company personnel

What percentage of your firm's business is conducted on behalf of the insurance industry?

What percentage of your business time is spent working for: Please specify for each category: Insurance Companies, Other private business, Governmental institutions, Private individuals, Other, Total (100%) )

Please provide details to above

Have you ever been or worked for a plaintiff in connection with an insurance matter other than a subrogation claim?

Yes
No

References & Endorsements

(Reference #1)

* Name

* Company

* Phone

* Address

* City

* State

* Zip Code

* Position

(Reference #2)

* Name

* Company

* Phone

* Address

* City

* State

* Zip Code

* Position

Endorsement by NSPII Full Member

* Name

* Company

* Phone

* Address

* City

* State

* Zip Code

* Position

* Name of NSPII member endorsing your application

* Date

Certification

By submitting this application, I certify that all of the information contained in this application is true and correct to the best of my knowledge. I authorize NSPII to investigate my background with respect to this application and release its officers, directors, and members from any liability in connection with their investigation. If accepted as a member, I agree to abide by the Society's Constitution and Bylaws and to adhere to its Code of Ethics.

* Signature

* Date

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