Loading
Form preview picture

Get Employer Statement

After passing the examination the completed Statement of Employer Form must be attached to the application for submission. Emp-Inst-02/06. STATEMENT OF EMPLOYER FORM PUBLIC ADJUSTER SECTION 2108 THIS FORM MUST BE COMPLETED BY THE EMPLOYER Employee s Name Date of Birth Social Security Number Employee s Address Telephone. EMP-1-02/06 No NOTICE TO EMPLOYER Before completing the statement of employer form and attesting to the employee s experience please read the following instructions to determine if the employee meets the experience requirements necessary to be exempt from the education requirements as prescribed by Section 2108 of the Insurance Law. If question 6a was answered Yes include the dates of employment below FROM Under penalty of perjury I affirm that I have completed this statement and the information set forth is true. DATE SIGNATURE OF EMPLOYER TITLE NOTE If the employer is a Corporation Partnership Limited Liability Company or Insurance Company this form must be signed by an officer director or member. Is/was the above employee regularly employed by the above employer for a period of not less than one year during the last three years in responsible insurance duties relating to the involvement in sales underwriting or claims Yes 6a. If question 6 was answered No Is/was the above employee regularly employed by the above employer in responsible insurance duties relating to the involvement in sales underwriting or claims for less than one year 6b. If question 6a was answered Yes include the dates of employment below FROM Under penalty of perjury I affirm that I have completed this statement and the information set forth is true. Number 5. Under what license number was the above employer continually licensed by the Superintendent of Insurance License Number 6. Is/was the above employee regularly employed by the above employer for a period of not less than one year during the last three years in responsible insurance duties relating to the involvement in sales underwriting or claims Yes 6a* If question 6 was answered No Is/was the above employee regularly employed by the above employer in responsible insurance duties relating to the involvement in sales underwriting or claims for less than one year 6b. If question 6a was answered Yes include the dates of employment below FROM Under penalty of perjury I affirm that I have completed this statement and the information set forth is true. DATE SIGNATURE OF EMPLOYER TITLE NOTE If the employer is a Corporation Partnership Limited Liability Company or Insurance Company this form must be signed by an officer director or member. Please note that if the experience relates to sales the applicant must have been licensed* Your signature will attest to the fact that the applicant was licensed to sell insurance. THE EMPLOYEE MUST --1. Be regularly employed for a minimum of one full year within the last three years. This employment may be with more than one employer. An employer must be a New York licensed insurance company with the property/casualty lines authority independent adjuster or public adjuster.

How It Works

employer statement form rating
4.8Satisfied
43 votes

Tips on how to fill out, edit and sign Statement from employer sample online

How to fill out and sign What is employer statement online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Choosing a authorized expert, creating a scheduled visit and going to the workplace for a private conference makes completing a Employer Statement Form from beginning to end exhausting. US Legal Forms allows you to rapidly generate legally valid papers based on pre-built browser-based samples.

Execute your docs in minutes using our straightforward step-by-step instructions:

  1. Get the Employer Statement Form you want.
  2. Open it up with online editor and begin adjusting.
  3. Complete the empty fields; involved parties names, addresses and phone numbers etc.
  4. Change the template with smart fillable fields.
  5. Include the date and place your e-signature.
  6. Click Done following double-examining everything.
  7. Download the ready-produced papers to your system or print it out like a hard copy.

Rapidly produce a Employer Statement Form without needing to involve experts. We already have over 3 million customers making the most of our unique collection of legal documents. Join us right now and gain access to the #1 catalogue of browser-based samples. Try it yourself!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Statement from employer FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Employer Statement Form

  • adjuster
  • ATTEST
  • Applicant
  • relates
  • exempt
  • completing
  • continually
  • submission
  • relating
  • requirements
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.