H. Certifications and Authorizations
By typing your name and checking the boxes below, you agree that this Application is an electronic record executed by you using your electronic signature and you acknowledge, and agree, to the certifications and authorizations set fourth below. 1. I hereby certify, under penalty of perjury, that all of the information submitted in this Application and all attachments is true and complete.
2. I hereby certify, under penalty of perjury, that I have never been convicted of a state or federal felony and that I am not prohibited by the Violent Crime Control and Law Enforcement Act of 1994 from engaging in the insurance business.
3. I hereby authorize Lexington National Insurance Corporation, Lexington National Bail Services, Inc., and/or American Safety Casualty Insurance Company (including any of its representatives, affiliates, agents or designees [collectively "you"] to conduct any and all investigative inquiries pertaining to me including obtaining consumer reports, investigative consumer reports, criminal records, driving records, and such other reports that it deems necessary. These inquiries and/or reports may include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I authorize you to request and obtain information from any federal, state and other agencies which may maintain records concerning my past activities relating to my credit, criminal, civil and other experiences, as well as claims involving me in the files of insurance companies. I authorize, without reservation, any party or agency contacted by you to furnish the above mentioned information. I acknowledge the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I specifically consent to you obtaining the above information from U.S. Datalink, National Credit Information Network (W.D.I.A.), or other sources deemed necessary. I hereby agree to execute any additional documents necessary to confirm the authorizations herein contained. This signed Application (including any copy of same) shall serve as written instruction on my behalf to any company to provide the requested information. I waive any rights I may have under the Fair Credit Reporting Act and Title 28 Privacy Act-Freedom of Information Act. I authorize you to furnish copies of the foregoing statement and any information provided herewith or hereafter obtained to your agents and to other companies for the purpose of securing reinsurance or co-suretyship.
By typing your name and checking the boxes above, you agree that this Application is an electronic record executed by you using your electronic signature and you acknowledge, and agree, to the certifications and authorizations set fourth above.