I certify that I am authorized to complete this application and that all of the information is true and correct.
I authorize represented carriers and their agents to obtain any and all information (including, but not limited to, work history, alcohol/controlled substance testing, training records, and criminal history) from previous and current employer(s), Medical Review Officers or their agents, DAC services, or other consumer reports, in accordance with State and Federal laws.
I authorize my previous and current employer(s) to release any information requested by the above carriers and hold them guiltless of all liability from release of said information.
I authorize the represented carriers express written consent to be contacted via phone call, email and/or text by this site, or on behalf of any third party software the carrier uses at the number(s) and/or email address you provided. You understand that these calls, text and/or email messages may be generated using an automated technology.
I have read and understand the above statements and acknowledge by affixing my digital signature below.