Fillable Employment Subscription Agreement Form Instructions Page 1 (IntelliCorp)

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Employment Subscription Agreement Form Instructions Page 1 (IntelliCorp)

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Employment Subscription Agreement Form Instructions
Page 1
Legal name required; trade
name can be listed as DBA
Federal Tax ID
Number; not state
Provide company website.
If you do not have one,
enter N/A
Appropriate box must be
checked. Indicate the
reason why your
organization is ordering
searches
Mailing and physical
address required. If they
are the same, indicate such.
If there are multiple
locations enter the primary
or HQ location
First and last name of
contact must be entered
Email address is required.
If you do not have an email,
enter N/A
Proof of Valid
Business or
“document type”
must be indicated
A brief description
(i.e. staffing company
and number of
employees are
required
Location: one
selection must be
made
Use primary phone
and fax numbers; do
not use direct lines.
If you do not have a
fax, enter N/A
Page 2
Company name must be
the same as what was
entered as Legal Name
and dba (if applicable) on
Page 1
State reflected must be
the State of incorporation
City and state
reflected in Physical
Address from Page 1
must be entered
here
Pages 3 & 4 do not require input, but must be submitted along with pages 1, 2, and 5
Page 5
Signature (‘wet’), Date,
Name, Title, and Email
must be entered
legibly. The document
must be signed by an
individual who has
authority to do so.
Electronic signatures
are not acceptable.
. Created 7-01-15
Version ICE2015.1
1. Please provide all requested information below (PLEASE TYPE OR PRINT).
2. Agreement must be signed by an owner, officer, director, partner, principal, or other representative legally authorized to bind the business.
3. Make copies for your files, mail originals to IntelliCorp; 3000 Auburn Drive, Suite 410; Beachwood, OH 44122 or you may fax to 216.450.5249 or email
to MVRCompliance@Intellicorp.net
ONE of the following MUST accompany this agreement: A CURRENT AND VALID BUSINESS LICENSE, OR A COPY OF ONE OF THE FOLLOWING dated
within the last 24 months : CURRENT STATE SALES AND USE TAX CERTIFICATE, OFFICIAL FEDERAL TAX DOCUMENTS - 940, 941, OR FEDERAL TAX
RETURN (W-9 is not acceptable)
Decline Automatic State Database Search - MO only
COMPANY INFORMATION
LEGAL NAME: _______________________________________________________________________
DBA: ________________________________________________________________________
FED TAX ID: ___________________
# of employees: _______
DESCRIPTION OF BUSINESS: _________________________________________________________
BUSINESS DOCUMENT ATTACHED
(check one):
940, 941 or Federal Tax Return
Business License
State Sales and Use Tax Certificate
Other Business Document
WEBSITE: ________________________________________________________________________
REASON FOR ORDERING SERVICES (check all that apply) :
Employment purposes (current or prospective employees)
Volunteer purposes (current or prospective volunteers)
Other purposes (please explain): ______________________________________________________
MAILING ADDRESS:
______
____________________________________________________________
ADDRESS 1
______
____________________________________________________________
ADDRESS 2
______
____________________________________________________________
CITY STATE ZIP
PHYSICAL ADDRESS
______
___________________________________________________________
ADDRESS 1
______
___________________________________________________________
ADDRESS 2
______
___________________________________________________________
CITY STATE ZIP
LOCATIONS (attach list if needed): ____________________________________________________________________________________________
BUSINESS LOCATION: COMMERCIAL (office or building) RESIDENTIAL (home-based or zoned residential)
CONTACT INFORMATION
PHONE NUMBER: ______________________/__________________________
BUSINESS ALTERNATE
FAX NUMBER: ______________________/__________________________
BUSINESS ALTERNATE
PRIMARY CONTACT NAME: __________________________________________________________________________________________________
PRIMARY CONTACT EMAIL: __________________________________________________________________________________________________
iiX USE ONLY
DATE
SOURCE
Intellicorp
SALES PERSON
TGC
ACCOUNT ID
PASSWORD
ACCT TYPE
NON
DETAIL PG
ACCESS FEE
RATE CLASS
N/A
998559
NAME
IntelliCorp
DIRECT BILL CODES
VERIFIED Date: Initials:
SET UP FEE
TERMS OF AGREEMENT MVRCompliance@Intellicorp.net
On-site visit Initials:
CALIFORNIA REQUESTER ID: _____________ (include CALIFORNIA COMMERCIAL REQUESTER ACCOUNT APPROVAL from state with agreement
iiX
Employment Subscription Agreement
Page 2 of 5
Created 7-01-15
Version ICE2015.1
Employment Subscription Agreement – Terms and Conditions
This subscription agreement (“the Agreement”) is entered into as of the date of execution below (the “Effective Date”), by and between ISO Claims
Services, Inc., a Delaware corporation, through its Insurance Information Exchange unit (“iiX”) with offices at 1716 Briarcrest, Suite 200 Bryan, TX
77802, and ______________________________________________________________________________________________(Customer Name),
a ______________ (State) corporation/other entity with offices at ________________________________________________________ (City, State).
1. SERVICES AND RATES. Certain reports, records, products and/or services, including Motor Vehicle Reports (“MVRs”) and other employment
screening reports (collectively, “Information Services”) will be provided to Customer under the terms specified in this Agreement. State-set record
fees are subject to change at any time.
2. SOLE USE AND OUTSOURCING. Customer warrants and agrees that the Information Services are to be used internally by Customer solely with
respect to (i) the continued employment of current employees or (ii) offers of employment to prospective employees, unless further restricted by
Specific State Forms (as defined below). Customer may deliver the Information Services to Customer’s employees and authorized users solely as
needed to perform functions consistent with this Agreement’s purpose. All such individuals shall be subject to this Agreement’s terms and conditions
and all applicable laws and regulations. Except as provided in Section 2.1, no one acting by or through Customer may sell, transfer, distribute
,
publ
ish, disclose, display or otherwise make the Information Services available, in whole or in part, or any of the information in them, to any other
person or entity, without the express written consent of iiX.
2.1 Use of Outsourcing Customer warrants and agrees that to the extent it has entered into or may enter into an arrangement with a third
party to provide services on Customer’s behalf (“Outsourcer”) to process Information Services, the arrangement shall be consistent with this
Agreement and solely for the purpose and benefit of Customer. The Information Services may be provided to Outsourcer solely to enable it to
assist Customer under this Agreement, provided that Customer, (1) as appropriate, discloses to any affected consumer(s) that his/her
information might be subject to outsourcing, including possible offshore access, and obtains the consumer’s permission for such access, and (2)
requires such Outsourcer, in writing, to confirm that it will (i) use the Information Services solely on behalf of or for the benefit of Customer, (ii)
abide by all Agreement terms and conditions regarding nondisclosure and use of the Information Services, and (iii) be subject to any applicable
laws and regulations, including but not limited to those governing privacy and the use of Personal Information (defined below). A copy of the
agreement between Customer and Outsourcer will be supplied to iiX upon iiX’s request.
2.2 Prohibitions Customer acknowledges that certain state and/or iiX data providers may prohibit access to their information by offshore
users. Customer agrees not to permit offshore access by any of its employees, authorized users, or Outsourcer in violation of any prohibition
against offshore access to records, and agrees to be responsible for the use of the Information Services by its employees, authorized users, or
Outsourcer in violation of this section.
Failure of Customer to comply in all respects with the requirements of this Section is a material breach of this Agreement. In such event, iiX may
immediately terminate this Agreement and the delivery of any Information Services to Customer without notice or delay.
3. RESTRICTIONS.
3.1 Confidentiality Customer acknowledges that in connection with this Agreement, it may receive Personal Information (defined below) and
nonpublic Personal Information from state agencies, service bureaus, and/or other data providers. Personal Information is information that
identifies an individual and includes, but is not limited to: (a) first and last name or first initial and last name; (b) a home or other physical address,
which includes at least street name and name of city or town; (c) an email address; (d) a telephone number; (e) a Social Security number; (f)
credit and/or debit card information, including credit and/or debit card number with expiration date; (g) date of birth; (h) a driver’s license number;
or (i) any other information from or about an individual consumer that is combined with (a) through (h) above. Consistent with Section 2 of this
Agreement, Customer agrees to treat as confidential all Personal Information received from or through iiX and to disclose such information only to
those authorized who have a need to know such information to accomplish their duties. Customer and its authorized users shall not use Personal
Information for any purpose except the purpose permitted by this Agreement.
3.2 Compliance with Laws Customer certifies that it shall order, receive, disseminate and otherwise use the Information Services in
compliance with all applicable federal, state and local statutes, rules, codes and regulations, including but not limited to, the Fair Credit Reporting
Act (“FCRA”), the Driver's Privacy Protection Act, 18 U.S.C. §2721 et seq. (“DPPA”), the Gramm-Leach-Bliley Act (“GLB”) and their state
equivalents, including any changes, supplements or amendments to such statutes, rules, codes and regulations (collectively, “The Laws”).
Customer further certifies that before ordering Information Services, it will comply with any applicable consumer disclosure-authorization and
adverse action requirements under the FCRA and will not use any information contained in the Information Services in violation of any applicable
federal or state equal opportunity law or regulation. Customer understands that violators of the FCRA, the DPPA, and other federal and state
laws governing protection of Personal Information are potentially subject to civil actions and penalties, including fines. Customer shall be
responsible for understanding and for staying current with all of The Laws. Customer further represents and warrants that it shall ensure the
security and confidentiality of Personal Information in compliance with The Laws. iiX acknowledges that it has appropriate administrative,
technical and physical safeguards, including data security safeguards, in place to protect Personal Information consistent with federal and state
requirements applicable to it.
Page 3 of 5
Created 7-01-15
Version ICE2015.1
3.2.1 Notification in Event of Breach or Misuse of Information Customer will immediately notify iiX of any inadvertent or unauthorized
release of any Information Services obtained under this Agreement or other security breach of Personal Information contained in Information
Services when the Customer knows of such unauthorized or inadvertent release. Customer agrees to notify all affected consumers in writing
that their Personal Information has been potentially compromised in the event of the Customer’s or its authorized users’, including any
Outsourcer’s, inadvertent or unauthorized release, misuse, or other security breach of Personal Information contained in the Information
Services supplied to Customer. Customer shall retain documentation of such notification and provide it to iiX and governmental
representatives immediately upon request
3.3 Specific State Forms Customer shall be responsible for understanding and for staying current with all specific state forms, certificates of use
or other documents or agreements, including any changes, supplements or amendments to them imposed by the states (collectively, “Specific
State Forms”) from which Customer will order Information Services. Customer certifies that it has filed all applicable Specific State Forms
required by individual states. If Customer receives Information Services from a state requiring a state form, Customer agrees that it shall sign a
copy of the appropriate state form and return it to iiX.
3.4 Publications Customer agrees that all solicitations, advertising copy and other communications used in connection with Information Services
shall be devoid of any reference to any selection criteria or presumed knowledge concerning the intended recipient of such solicitation, or the
source of the recipient's name and address. Customer further warrants that telephone numbers submitted to iiX for reverse telephone append
matching services will not be randomly generated or obtained by an automatic number identification system, except where a prior business
relationship exists between Customer and the owner of such telephone number.
3.5 Archiving Customer and any of its authorized user(s), including any Outsourcer, shall not use Information Services supplied by or through
iiX, or data derived from them, including any MVR data, to directly or indirectly compile, store, or maintain the Information Services or derivative
data (independent of or commingled with other databases) to develop its own source or database of such services or data.
3.6 Other Restrictions iiX may from time to time impose additional restrictions, procedures or processes upon the use and/or delivery of the
Information Services that it believes to be prudent to ensure compliance with The Laws, the Specific State Forms and/or the security, privacy or
confidentiality of the Information Services.
3.7 Interpretation In the event that Customer and iiX disagree about the intent, effect, necessity to comply with or the interpretation and/or
compliance requirement of any of The Laws or Specific State Forms, Customer shall conform to iiX’s interpretation.
3.8 Use of the Internet Customer and any of its authorized user(s), including any Outsourcer, will not disseminate any unsecured or
unencrypted Information Services over the Internet. Internet dissemination includes e-mail, World Wide Web access, FTP and all other
mechanisms where data is transmitted across the Internet. This shall not prohibit Customer from transmitting such information over a secure
network to Customer’s authorized users with a legitimate need to receive the information, provided that such actions comply with The Laws as
well as any other state and federal statutes and regulations governing the confidentiality, security and transmission of the Information Services.
Failure of Customer to fully comply with the requirements of all of Section 3 shall be a material breach of this Agreement and shall permit iiX to
immediately terminate this Agreement and the delivery of any Information Services to Customer without notice or delay.
4. WARRANTY AND INDEMNIFICATION. Customer represents and warrants that any data, content or other materials provided by Customer to iiX
are in compliance with all applicable laws and will not, when used by iiX, defame any person or infringe the trademarks, service marks, copyrights or
other intellectual property rights of any third party. Customer agrees to indemnify and hold harmless iiX, its affiliated companies and their officers,
directors, employees and shareholders from any and all damages, costs, judgments and expenses (including reasonable attorney’s fees) as well as
any and all fines, interest, penalties or any other liabilities: (i) incurred by iiX, (ii) imposed by local, state or federal authorities or (iii) claimed by any
third party, that result from or arise out of Customer’s failure to fully comply with the provisions of Sections 2, 3 and 4 or the use by Customer or its
authorized users, including any Outsourcer, of the Information Services provided under this Agreement.
5. TERMINATION. Customer may terminate this Agreement at any time with thirty (30) days prior written notice to iiX. Customer agrees, however, to
pay for all requests received by iiX prior to termination. Except as provided in Sections 2 and 3, iiX may terminate this Agreement or amend services
pr
ovided under it by providing ten (10) days prior notice to Customer. iiX may amend this Agreement or terminate it without notice if the availability of
an Information Service to iiX changes for any reason during the term of this Agreement.
6. DISCLAIMERS.
CUSTOMER UNDERSTANDS AND AGREES THAT THE FOLLOWING LIMITATIONS ARE AN ESSENTIAL PART OF THE CONSIDERATION TO
iiX FOR ENTERING INTO THIS AGREEMENT. THE LIMITATIONS ARE SPECIFICALLY DESIGNED AND AGREED TO BY THE PARTIES TO
ALLOCATE AND LIMIT RISKS BETWEEN THE PARTIES IN LIGHT OF THE PRICES CHARGED AND THE OTHER BUSINESS TERMS OF THIS
AGREEMENT.
CERTAIN OF THE INFORMATION SERVICES PROVIDED UNDER THIS AGREEMENT ARE FROM INFORMATION OR SERVICES SUPPLIED BY
VARIOUS STATE AGENCIES, SERVICE PROVIDERS, AND OTHER SERVICE BUREAUS (COLLECTIVELY, “DATA PROVIDERS”). THE
INFORMATION SERVICES ARE PROVIDED "AS IS" AND NEITHER iiX NOR ITS DATA PROVIDERS IN ANY WAY WARRANT OR ASSUME ANY
Page 4 of 5
Created 7-01-15
Version ICE2015.1
L
IABILITY FOR THE ACCURACY, TIMELINESS, MERCHANTABILITY, FITNESS FOR PARTICULAR PURPOSE AND/OR COMPLETENESS OF
ANY INFORMATION SERVICE PROVIDED UNDER THIS AGREEMENT.
AT THE DISCRETION OF THE CUSTOMER, WHERE PERMITTED, MOTOR VEHICLE REPORTS MAY BE SUPPLIED FROM DATABASE OR
HISTORY FILES. THESE DATABASE REPORTS MAY NOT CONTAIN THE SAME DATA AS A CURRENT STATE REPORT. THE REPORT WILL
BE NOTED AS A DATABASE REPORT AND WILL SHOW THE ORIGINAL REPORT DATE.
NEITHER iiX NOR ITS DATA PROVIDERS ASSUME RESPONSIBILITY FOR CHARGES INCURRED, LOST REVENUE, OR INCIDENTAL,
SPECIAL, PUNITIVE OR CONSEQUENTIAL DAMAGES OF ANY KIND OR NATURE DUE TO ANY CAUSE WHATSOEVER, INCLUDING, BUT NOT
LIMITED TO, ERRORS IN CUSTOMER INPUT, DUPLICATE REQUESTS, ERRORS IN TRANSMISSION, PROGRAM OR EQUIPMENT FAILURES,
COMMUNICATION PROBLEMS, PROCESS DELAYS, OR SCHEDULE CHANGES. IN NO EVENT SHALL iiX'S OR THE APPLICABLE DATA
PROVIDER’S LIABILITY EXCEED THE CHARGES ACTUALLY PAID TO iiX BY CUSTOMER IN THE THREE (3) MONTHS IMMEDIATELY
PRECEDING ANY SUCH CLAIM.
7. CREDENTIALING. Credentialing is the process for verifying that entities are legitimate and their purpose for the use of the Personal Information is
authorized
7.1 Pre-Service Review iiX will verify Customer’s identity and permissible purpose to request Information Services through a certification or pre-
service review. This review may include but not be limited to a verification of the type of business, confirmation that the stated permissible
purpose for obtaining the product or service is compatible with the type of business conducted, conducting a physical inspection of the premises
to assure that it is a legitimate business facility, verification of specified credentials, and verification of business phone and address records and
web pages through the use of recognized third parties. Customer agrees to cooperate fully with any certification process or pre-service review
prior to iiX permitting access to Information Services.
7.2 Credential Monitoring Customer further agrees to cooperate fully with continued monitoring of Customer credentials. Monitoring includes
the recertification of credentials and update of this Agreement. iiX reserves the right to make such requests as it deems necessary. Failure to
comply could result in restriction or termination of access to Information Services.
8. AUDIT. Upon receipt of iiX audit requests, Customer agrees to respond within the time period specified in the audit notice or request for
information. Customer shall provide all documentation as requested. This information shall be made available to iiX for review and copying upon iiX’s
request or to any governmental authority upon request. Access privileges to the Information Services will be suspended upon failure to comply with
such requests. Customer agrees that it will not obstruct a governmental authority’s audit at the Customer’s site in connection with the ordering or us
e
of
Information Services.
9. RETENTION OF INFORMATION.
9.1. Retention of Information Services Materials and Data Customer and its authorized users, including any Outsourcer, shall promptly and
adequately destroy the Information Services (including MVRs) in its/their possession when they are no longer required for the purpose as stated
in this Agreement.
9.2. Retention of Requestor Information Customer must maintain records identifying each person or entity that receives the Personal
Information and the permitted purpose for which the Personal Information will be used. These records must be retained for a period of (5) five
years and shall include, but not be limited to, the: request date, requested individual, requestor, permissible purpose for each Information Service,
and, as appropriate, signed disclosure/authorization forms from affected consumer(s).
9.3 Destruction of Information All documents containing Personal Information that have been obtained from or through iiX must be properly
disposed of by taking reasonable measures to protect against unauthorized access to or use of the information in connection with its disposal.
This would include, but not be limited to, implementing and monitoring compliance with policies and procedures that require the burning,
pulverizing, erasing, or shredding of papers or records containing such information so that the information cannot practicably be read or
reconstructed. Electronic files or media containing Personal Information must be destroyed or erased so that the information cannot be read or
reconstructed.
10. INDEPENDENTLY CONTRACTING PARTIES. The relationship of the parties shall be that of independently contracting parties. Nothing in this
Agreement shall be construed to create any partnership, joint venture, agency or other similar relationship. Neither party shall have the right or
authority to create, assume or imply any obligation or responsibility on behalf or in the name of the other party or bind the other party in any manner.
11. NOTICES. Notices sent to either party shall be effective when delivered in person, one day after being sent by overnight courier, or five (5) days
after being sent by certified mail postage prepaid to the address set forth above for such party, or to such other address as the party, to which such
notice is being sent, may from time to time have specified in an earlier notice to the party sending such notice. In addition, notices to Customer sent by
email to Customer’s email address identified in this Agreement shall be effective when sent. Customer shall notify iiX of any changes in Customer’s
email address.
12. CHOICE OF LAW. This Agreement shall be governed by and construed in accordance with the substantive laws of the state of New York. The
state or federal courts of the State of New York shall have exclusive jurisdiction over any claims arising out of or in any way related to this Agreement.
Page 5 of 5
Created 7-01-15
Version ICE2015.1
13. FORCE MAJEURE. Except for payment obligation, neither party shall be liable for any failure or delay in performance directly or indirectly caused
by acts or omissions beyond the reasonable control of the party required to perform. In the event that a party is asserting force majeure as its reason
f
or failing to timely perform, such party shall immediately notify the other party of the situation and shall use every reasonable effort to remove the
condition of force majeure and begin performance.
14. MISCELLANEOUS. This document and any amendments as well as the Exhibits, if any, referenced in this Agreement and all documents referred
to in its Exhibits, if any, constitute the entire agreement between the parties with respect to the subject matter of this Agreement and supersede all
other communications, whether written or oral. Except as set forth in Section 3.6, this Agreement may be modified or amended only in a writing si
gned
by
both parties. Waiver of any provision in this Agreement in one instance shall not preclude its enforcement in the future. Headings are for reference
purposes only and have no substantive effect.
15. SEVERABILITY. The provisions of this Agreement shall be severable, and if any provision of this Agreement shall be held or declared to be
illegal, invalid or unenforceable, such illegality, invalidity, or unenforceability shall not affect any other provision, and the remainder of this Agreement,
disregarding such invalid portion, shall continue in full force and effect as though such invalid provision had not been contained in the Agreement.
16. SURVIVAL. The provisions of Sections 2, 3, 4, 5, 6, 8, 9, 10, 11, 13, 14, and 15 of this Agreement shall survive the expiration, cancellation,
termination or non-renewal of this Agreement.
17. COUNTERPARTS. This Agreement may be executed in two or more counterparts, each of which shall take effect as an original and all of which
together shall evidence one agreement.
18. ASSIGNMENT. Customer shall not assign or subcontract this Agreement without the prior written permission of iiX and any such assignment or
delegation, either full or partial, to any third party is void and of no effect. A merger, consolidation, reorganization or other change of control shall be
considered an assignment for the purposes of this Agreement. All terms and provisions of this Agreement shall be binding upon and inure to the
benefit of the parties to it and their respective permitted transferees, successors and assigns.
T
HE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ, UNDERSTANDS, AND AGREES TO THE TERMS AND CONDITIONS DESCRIBED
IN THIS SUBSCRIPTION AGREEMENT, AND ANY APPLICABLE STATE AGREEMENTS. THE UNDERSIGNED FURTHER AFFIRMS THAT THE
STATEMENTS MADE IN THIS AGREEMENT ARE TRUE AND CORRECT, THAT HE/SHE HAS DIRECT KNOWLEDGE OF THE FACTS
CERTIFIED IN THIS AGREEMENT, AND THAT HE/SHE HAS AUTHORITY TO MAKE THE ABOVE REPRESENTATIONS AND TO ENTER INTO
THIS AGREEMENT AS A PERSON LEGALLY AUTHORIZED TO BIND THE COMPANY (OWNER, OFFICER, DIRECTOR, PARTNER, PRINCIPAL,
OR OTHER REPRESENTATIVE WHO IS LEGALLY AUTHORIZED TO BIND THE BUSINESS).
SIGNATURE:____________________________________________________________________DATE:______________________
Owner or Officer or Legally Authorized Representative
N
AME (Printed):___________________________________________________TITLE:_____________________________________
E
-MAIL ADDRESS OF SIGNEE:_________________________________________________________________________________
DIRECT HIRE STATEMENT
Company Name: _________________________________________________
Company Address: _______________________________________________
________________________________________
________________________________________
We understand that the records or reports obtained through iiX will be used only by our aforementioned
company listed above, in the hiring of employees working directly for our company. We acknowledge that
the records or reports cannot be used for the verification of prospective/employees at our affiliated
companies. Records or reports obtained will not be passed on to any other prospective employers or third
parties and will remain in the possession of our company.
We understand that the reason iiX is requesting this information is that our company’s website or other
information suggests that the records or reports could be viewed/used by another party.
_______________________________________
Signature
_______________________________________
Title
_______________________________________
Date
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Employment Subscription Agreement Form Instructions Page 1 (IntelliCorp)

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Completed 29 July 2020

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