Felony convictions either State or Federal, felony convictions involving dishonesty or breach of trust, embezzlement,
fraud, perjury, tax fraud, misdemeanor convictions for assault and battery, convictions for driving while
intoxicated or under the influence of drugs or other substances, which have occurred within seven (7)
years of the date you submit this form. The information will be disclosed for the following purposes:
Investigation into criminal background for purposes of engaging the undersigned individual as an Independent
Contractor. I understand that the information described above may be re-disclosed and no longer protected
by federal and state privacy regulations. I further understand that I may revoke this authorization in
writing at any time by sending or faxing a written notice to the disclosing party above. This written
revocation must state my intent to revoke this authorization. A facsimile, copy, or photocopy of this
authorization shall be as valid as the original.
Convictions:
I hereby affirm that the information set forth above is true and correct. I understand that if any of the information given
above is not true and correct, then I have misrepresented information to AmerAdjust LLC and am subject
to immediate dismissal from any catastrophe site. I further understand that, due to any misrepresentations
made herein, AmerAdjust LLC may be penalized for any false statements above. Should the information given
herein be incorrect, I affirm I will reimburse AmerAdjust LLC for any and all penalties. I further understand
that this information contained herein shall be held in strictest confidence by AmerAdjust LLC, its agents,
employees and/or servants. I have freely and voluntarily given the information above for the purposes
of becoming an independent contractor to be used in the capacity of adjusting insurance claims for AmerAdjust
LLC and its clients or for any other capacity in which AmerAdjust LLC might use my services. By signing
this form, I agree that AmerAdjust LLC may conduct an in-depth background check at any time within one
year from the date below.