2014 WIND Umpire Directory

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Marjory Williamson
8 years ago
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1 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. 1. APPLICANT INFORMATION Name Title Company Address City State Zip Phone Fax 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/ CONTINUED ON NEXT PAGE WIND reserves the right to edit directory submissions for clarity and brevity. Proofs will be faxed before final printing.

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

2 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 Attorney (Plaintiff) Attorney (Defense Mediator Contractor Independent Adjuster Public Adjuster CPA/Accountant Engineer 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) CONTINUED ON NEXT PAGE WIND reserves the right to edit directory submissions for clarity and brevity. Proofs will be faxed before final printing.

Contractor Independent Adjuster Public Adjuster CPA/Accountant Engineer Other Occupation (Must Specify) 6.

3 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 ed to membership@windnetwork.com. 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 ( 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 at membership@windnetwork.com. b) Mail: In Florida, visit the FDLE website ( 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 Results may take up to seven business days. Please note: If you elect to have the results sent back to you, you must or mail the results to WIND, Attn: Umpire Directory, 2929 Langley Ave, Suite 203, Pensacola, FL or via at membership@windnetwork.com. (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 to pay dues online or to download a 2014 membership application/renewal form. q AMEX q Discover q Mastercard q Visa q PayPal (You must pay online to use the PayPal option) Card # Exp. Date Auth. Code (last 3 digits on back of MC and VISA, front 4 digits on AMEX) Billing Address Signature Mail to: Windstorm Insurance Network, Inc Langley Avenue, Suite 203 Pensacola, FL Fax to (credit cards only) 11. FOR MORE INFORMATION Contact the Windstorm Insurance Network, Inc. at or fax us at Our address is info@windnetwork.com. For more information, visit

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.

American College of Legal Medicine Application for Membership

I. Membership Categories I am applying for: American College of Legal Medicine Application for Membership o FELLOW ($100 member application fee*, $325 annual dues) A professional with either an MD, DO,