MileAuto Background check form

Mile Auto Appointment Application

Personal information

First Name*

Last Name*

Middle Name Initial*

Gender*

SSN*

Home Phone #*

Date of Birth*

Residency Address, Building or Apt #*

Residency City*

Residency State*

Residency Zip Code*

Agency information

Agency Name*

Agency Phone #*

Business Email Address*

Agency Mailing Address*

Agency City*

Agency State*

Agency Zip Code*

Agent Licensing Information

License Number*

License State*

Line of Authority*

I understand that to process my application and to evaluate me for licensing purposes, initial state appointment or renewal of state appointments, I may be subject to an investigative consumer report ordered by Mile Auto, Inc. as required by certain states. I further understand that the investigative report may consist of credit reports; criminal record reports; regulatory inquiries such as state insurance, banking or securities department inquiries; SEC or NASD inquiries and interviews with and inquiries to third parties, such as former employers, financial sources and others. I authorize LotSolutions Inc. to conduct any of these inquiries on behalf of its affiliated Insurance companies. I authorize, without reservation, any party or agency contacted by Mile Auto, Inc., its agents, member companies and/or affiliates to furnish the above-mentioned information.

Applicant's Signature*

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Date*

Mile Auto Appointment Application

Personal information

Agency information

Agent Licensing Information

Background Information