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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.

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