RE: TITLE 28 PRIVACY ACT, FREEDOM OF INFORMATION ACT, TITLE 6 FAIR CREDIT REPORTING PUBLIC LAW 91-508
I understand that investigative inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. I also understand that you will be requesting information from various federal, state and other agencies which maintain records concerning any past activities relating to my credit, criminal, civil and other experiences as well as claims involving me in the field of insurance.
I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information about me to you.
I have a right to make a written request within a reasonable period of time to receive additional information about the nature and scope of this investigation.
I hereby consent to your obtaining the above information and agree that, if appointed with you, such information you obtain along with information relating to my performance with you will be accessible through you by future insurance companies to which I might apply.
I certify that each statement therein made is full, true and correct to the best of my knowledge.
I agree that pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 18 United States Code Sections 1033, 1034, I will notify O'ShaughnaHill Surety & Insurance, Inc., in writing, within 30 days of my being convicted of a felony.
Applicant Authorization
O'Shaughnahill Surety & Insurance, Inc. (OSI) is required by law to protect applicants and customers nonpublic personal financial information.
O'Shaughnahill Surety & Insurance, Inc. will not disclose the nonpublic personal financial information of applicants and customers except as permitted by law.
We collect your nonpublic personal financial information from the following sources:
- Information obtained from you, including information from your application, such as name, address, telephone number, social security number, assets, and income
- Information from business entities about transactions and experiences, such as your premium payment and claims history
- Information from a consumer reporting agency, such as your credit history
O'Shaughnahill Surety & Insurance, Inc. maintains electronic, physical, and procedural safeguards that comply with Federal regulations to protect your nonpublic personal financial information. We limit access to your nonpublic personal financial information to those employees who need to know that information to perform their job responsibilities
As the applicant, you certify that there are no misrepresentations, omissions, or falsifications in the forgoing statements and answers. You certi-fy that the entries made above are true, complete, full, and correct to the best of your knowledge and belief and are made in good faith.
You authorize the legal agencies, any person, former employers, or corporations having personal knowledge about you to give any information or answer all questions asked concerning your ability, work, or moral character in connection with this application.
You further agree and consent that in the event this application is found to contain false statement(s), omission of material information, or misrepresentation of any kind, this application may be disapproved, disallowed, or cancelled without the showing of any further cause.
You consent that a photocopy of this authorization is to be accepted with the same authority as the original.
You understand this authorization and the information gathered is to be part of your permanent
file and business records maintained by O'Shaughnahill Surety & Insurance.
