Please print the application and fill it out completely.

Then return the application to the address below.

PLEASE PRINT CLEARLY

Name: __________________________________________________

Company: _______________________________________________

Mailing Address: ___________________________________________

___________________________________________

Phone Number: ___________________________

Fax: ___________________________

Email Address: ______________________________________________

Status: _____ Renewal _____ New Member

General Membership – Insurance related support services employment

COST: $25.00 (Circle One)

Claims Adjuster Supervisor/Manager Investigator Engineer

Legal/Attorney

Other: ______________________________________________

Vendor Membership – Insurance related services provider employment

COST: $30.00 (Circle One)

Auto Rental Auto Repair Contractor Clean Restoration

Salvage Temporary Housing Dry Cleaner

Other: __________________________________________________

Signature _________________________________ Date _____________

Office Use Only

Email _____ Add _____ Verify _____

Initial __________ Date __________

Mail Application To:

Cleveland Claims Association
P.O. Box 305
Cleveland, Ohio 44017