Background Information And Authorization

Transcription

1 Background information Please respond to all questions for you personally and any organization over which you have exercised control. If you answer yes to any questions, you must attach a signed and dated explanation with all relevant information, including dates and supporting documents. (yes answer response template available) 1. Have you or an officer of your company ever had: a. your insurance license or any professional license, or FINRA registration suspended or revoked?... Yes No b. a regulatory or consumer complaint filed against you with an insurance department, the SEC, a state securities department or FINRA?... Yes No c. any reportable events on your U-4 or U-5... Yes No 2. Have you or an officer of your company ever been charged with or convicted of a crime that was a a. felony?... Yes No b. misdemeanor?... Yes No 3. Have you or an officer of your company ever been involved in: a. any litigation... Yes No b. bankruptcy... Yes No c. litigation or arbitration in which you and NPLH had any opposing claims?... Yes No 4. Do you or an officer of your company currently have a state, federal or other taxing authority tax lien or judgement?... Yes No 5. Do you have any debt collection matters pending against you?... Yes No 6. Do you have any charged off debt items?... Yes No 7. Have you had any foreclosures within the last three years... Yes No 8. Do you or an officer of your company have any outstanding debt(s) with any insurance marketing organization, insurance company(ies), or broker/dealer?... Yes No 9. If you are an individual, are you an employee of NPLH or one of NPLH s subsidiaries?... Yes No 10. Are any immediate family members currently contracted with NPLH?... Yes No 11. How many years have you resided in the State and County of residence and county of work for the address in this application? Years Explanation for yes answered questions (use additional sheet if necessary Background Question # Action: Date of Action: Reason: Explanation: Background Information And Authorization Resolution: Background Question # Action: Date of Action: Reason: Explanation: Resolution: 1

2 WRITTEN DISCLOSURE AND CONSENT TO REQUEST CONSUMER REPORT AND/OR INVESTIGATE CONSUMER REPORT INFORMATION Disclosure Regarding Background Investigation for Employment Purposes National Prosperity Life And Health Insurance Company, and other entities related to it by common ownership or affiliated by corporate control (collectively referred to as National Prosperity Life And Health Insurance Company ) may request background information about you from a consumer reporting agency for the purpose of evaluating you for employment, promotion, reassignment or retention as an employee. Note that background information on individuals performing certain services for National Prosperity Life And Health Insurance Company on an independent contractor basis may be deemed to be for employment purposes as defined by under section 603(h) of the Fair Credit Reporting Act. This background information may be obtained in the form of consumer reports and/or investigative consumer reports. With the exception of applicants and/or employees in California, these reports may be obtained at any time after receipt of your authorization and during your affiliation with National Prosperity Life And Health Insurance Company. True Hire prepares or assembles consumer reports and/or investigative consumer reports for National Prosperity Life And Health Insurance Company. True Hire is located and can be contacted by mail at Cleveland Avenue Uniontown, OH 44685, and can be contacted by phone at The reports may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to: address history; credit reports and history; criminal records; public court records; driving records; bankruptcy filings; educational history; employment history; personal and professional references checks; professional licensing; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The information may be obtained trough personal interviews with sources such as neighbors, friends, and associates; and other information sources. You may request, in writing, within a reasonable time, a more detailed explanation regarding the nature and scope of any investigative consumer report to be conducted. You also have the right to request a copy of your consumer and/or investigative consumer report from the consumer credit reporting agency by checking the box on the attached consent form. The report will be mailed directly to you by the consumer reporting agency. A summary of your rights under the Fair Credit Reporting Act is also being provided to you. 2

3 WRITTEN DISCLOSURE AND CONSENT TO REQUEST CONSUMER REPORT AND/OR INVESTIGATE CONSUMER REPORT INFORMATION Disclosure Regarding Background Investigation for Employment Purposes National Prosperity Life And Health Insurance Company, and other entities related to it by common ownership or affiliated by corporate control (collectively referred to as National Prosperity Life And Health Insurance Company ) may request background information about you from a consumer reporting agency for other than the employment purposes as authorized by the Fair Credit Reporting Act. Such purposes include, but are not limited to use of the information in connections with: a credit transaction involving you; the underwriting of insurance involving you; a determination of your eligibility for a license or other benefit granted by a governmental instrumentality required by law to consider an applicant s financial responsibility or status; a business transaction initiated by you for which National Prosperity Life And Health Insurance Company has a legitimate business need for the information; or any credit or insurance transaction that is not initiated by you when you have authorized agency to provide us with such a report. This background information may be obtained in the form of consumer reports and/or investigative consumer reports. With the exception of applicants and/or employees in California, these reports may be obtained at any time after receipt of your authorization and during your affiliation with National Prosperity Life And Health Insurance Company. In addition, a consumer reporting agency may furnish a consumer report in accordance with the written instruction of the consumer to whom it relates. True Hire prepares or assembles consumer reports and/or investigative consumer reports for National Prosperity Life And Health Insurance Company. True Hire is located and can be contacted by mail at Cleveland Avenue Uniontown, OH 44685, and can be contacted by phone at The reports may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained include, but are not limited to: address history; credit reports and history; criminal records; public court records; driving records; bankruptcy filings; educational history; employment history; personal and professional references checks; professional licensing; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The information may be obtained trough personal interviews with sources such as neighbors, friends, and associates; and other information sources. You may request, in writing, within a reasonable time, a more detailed explanation regarding the nature and scope of any investigative consumer report to be conducted. You also have the right to request a copy of your consumer and/or investigative consumer report from the consumer credit reporting agency by checking the box on the attached consent form. The report will be mailed directly to you by the consumer reporting agency. A summary of your rights under the Fair Credit Reporting Act is also being provided to you. 3

4 WRITTEN DISCLOSURE AND CONSENT TO REQUEST CONSUMER REPORT AND/OR INVESTIGATE CONSUMER REPORT INFORMATION Additional State Law Notices CALIFORNIA: You have the right to inspect visually the files concerning you maintained by an investigative consumer reporting agency during normal business hours and upon reasonable notice. The inspection can be done in person if you appear in person and furnish proper identification. You are entitled to a copy of the file for a fee not to exceed the actual costs of duplication. You are entitled to be accompanied by one person of your choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if you make a written request, with proper identification, for copies to be sent to a specified addressee. You can also request a summary of the information to be provided by telephone at phone number if you make a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call if prepaid by or directly charged to you. You further understand that the investigative consumer reporting agency shall provide trained personnel to explain to you any of the information furnished to you. You shall receive from the investigate consumer reporting agency a written explanation of any coded information contained in files maintained on you. Proper identification as used in this paragraph means information generally deemed sufficient to identify a person, including documents such as a valid driver s license, social security account number, military identification cad and credit cards. Information about the investigative consumer reporting agency s privacy practices related to the consumer s personal information may be found at (bottom of web page at the Legal/Privacy link). MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and, if one was requested the name and address of the consumer reporting agency furnishing the report. You may request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such consumer reporting agencies copies of any such investigative consumer reports. MINNESOTA: You have the right, upon written request, to obtain from the consumer reporting agency that prepares any such report a complete and accurate disclosure of the nature and scope of any report prepared. NEW YORK: You have the right, upon request, to be informed of whether a consumer report was requested, and, if one was requested, the name and address of the consumer reporting agency furnishing the report. Upon written request you will be informed about whether or not an investigative consumer report was requested, and if such report was requested, the name and address of the consumer reporting agency to whom the request was made. You may inspect and receive a copy of such report by contacting such agency. Enclosed for your information is a copy of New York State Correction Law 753, Factors To Be Considered Concerning A Previous Criminal Conviction; Presumption. 4

5 New York State Correction Law Article 23-A, Section 753 Licensure and Employment of Persons Previously Convicted of One or More Criminal Offenses 753. Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination pursuant to section seven hundred fifty-to of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein. 5

6 Background Release Form In connection with this application for employment, I understand that an investigative consumer report may be requested now by True Hire, and in the future as terms of my continued employment. This report may include information pertaining to my character, education, work history, credit history, motor vehicle records, and criminal information contained within any government agency, Federal, State, or Local. This information shall include, but not be limited to, verifying any statements made on my application. I hereby authorize all corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies, military services, and former employers to release information they may have about me to Company or its agents, and do forever release them from any liability or responsibility for doing so to the fullest extent allowed by law from any claims arising from the requested information. If required, I specifically authorize a credit report to be obtained on myself. If required, I specifically authorize workers compensation claim information to be obtained on myself by True Hire. I recognize and agree that a copy or facsimile of this document shall be as valid as the original and agree that this release shall be valid for this and any future update reports requested. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied based on information contained in this report, and to receive, upon written request, a disclosure of the public record information as well as the nature and scope of the investigative report. Confidential Information Used for Background Checking Purposes PRINT FIRST NAME MIDDLE INITIAL LAST SOCIAL SECURITY NUMBER DATE OF BIRTH DRIVER S LICENSE NUMBER STATE OF ISSUANCE PRESENT ADDRESS CITY, STATE, ZIP COUNTY Please list any previous addresses you have had in the past 7 years: PREVIOUS ADDRESS CITY, STATE, ZIP COUNTY PREVIOUS ADDRESS CITY, STATE, ZIP COUNTY PREVIOUS ADDRESS CITY, STATE, ZIP COUNTY Please list any former names (I.e. maiden or otherwise) you have used in the past 7 years: Please list any former felonies or misdemeanors you have been convicted of in the past 7 years (Please list date, charge, location, disposition): Signature Date Cleveland Ave NW., Uniontown, OH TEL FAX info@true-hire.com 6