Independent Contractor

Background Check Authorization and Release

Residential and Commercial Claims Adjusters _________________ P 641.469.5900 F 309.439.5900 _________________ hr@wgclaims.com www.wgclaims.com _________________
PO Box 572
Fairfield IA 52556

The Insurance Prevention Act of 1994, Title 18, U.S.C., Sections 1033 and 1034, was enacted for the purpose of governing crimes by or affecting persons engaged in the business of insurance whose activities affect interstate commerce. In compliance with this act and in connection with my application for independent contractor deployment with Walker Group Inc. (WGI), I hereby authorize WGI or its agent to obtain a consumer report, or investigative consumer report which may include information on my criminal history, driving records, character, and general reputation from public record sources or through personal interviews with previous employers, associates, or educational institutions. Only information relevant to the performance of job duties will be requested or utilized, and all information received will be kept strictly confidential unless otherwise agreed to. I hereby authorize, without reservation, any person or entity contacted by WGI or its agent, to furnish the above stated information, and I release any such person or entity from any and all liability for furnishing such information. I further release WGI and its affiliated companies, their officers, employees, and contractors, from any and all liability and responsibility arising from the preparation of said report. I understand that false or misleading statements made in the application process for deployment as an Independent Property Adjuster with WGI will disqualify me from consideration for deployment or result in immediate termination if deployed. I understand I have the right, upon written request, to receive a written description of the nature and scope of any investigation WGI may request, and a written summary of your rights under the Fair Credit Reporting Act. I HEREBY ACKNOWLEDGE THAT I HAVE READ AND AGREE TO THE TERMS OF THIS DOCUMENT:

________________________________________ Signature

___________________ Date

_______________________________ __________ ________________________ Full Name DOB* SS# *Date of Birth will be used solely for purpose of identification in doing background checks and will not be considered for any other purpose.