In connection with my Independent Agent Agreement, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: workers’ compensation injuries, driving record, court record, education, credentials, credit, and references.
Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if contract is not accepted because of information obtained by the contracting company from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.
I acknowledge that a facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid all most federal, state and county agencies including all state Departments of Labor.
If you want a copy of the report(s) ordered, check the box when prompted below.
The report(s) will be sent to you at the address below.
I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by the reporting agency or its agent, to furnish the information described in Section 1. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the contracting company and agents and all person, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports.
I acknowledge that the foregoing authorization shall continue in force until revoked by me in writing.
The Following states require sex and race to obtain information: AL, AR, FL, GA, IA, IN, OR, TX, WI.
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