PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I shall not at any time in the future represent a Citizens policyholder in a claim against Citizens for which I provided services or gained knowledge about as a employee or sub-contractor of Vendor. This would include acting as a consultant, public adjuster, witness or any other capacity related to the policyholder’s claim against Citizens. Acknowledged and Agreed to on the following date: , 20 , by: Name (print or type): Signature: Exhibit B - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 Indicate with an "x" the License Type & Number: C: Name of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Degree or Certification Earned Field of Study or Certification Title Please list education and certifications/licensing NOT listed above: Institution Name Years Completed Associate of Insurance Services (AIS) Certified Insurance Fraud Investigator (CIFI) Chartered Property Casualty Underwriter (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglary, Theft, Vandalism Sinkhole Water, Plumbing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:
Appears in 1 contract
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I shall not at any time in the future represent a Citizens policyholder in a claim against Citizens for which I provided services or gained knowledge about as a employee or sub-contractor of Vendor. This would include acting as a consultant, public adjuster, witness or any other capacity related to the policyholder’s claim against Citizens. Acknowledged and Agreed to on the following date: , 20 , by: Name (print or type): Signature: Exhibit B - Contract between Citizens and Eagle Eye Investigative SolutionsDELTA ASSOCIATED INVESTIGATIONS, LLC INC. DBA DELTA GROUP Contract # 18-18-0031-03 02 Indicate with an "x" the License Type & Number: C: Name of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Degree or Certification Earned Field of Study or Certification Title Please list education and certifications/licensing NOT listed above: Institution Name Years Completed Associate of Insurance Services (AIS) Certified Insurance Fraud Investigator (CIFI) Chartered Property Casualty Underwriter (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglary, Theft, Vandalism Sinkhole Water, Plumbing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative SolutionsDELTA ASSOCIATED INVESTIGATIONS, LLC INC. DBA DELTA GROUP Contract # 18-18-0031-03 02 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:
Appears in 1 contract
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I shall not at any time in the future represent a Citizens policyholder in a claim against Citizens for which I provided services or gained knowledge about as a employee or sub-contractor of Vendor. This would include acting as a consultant, public adjuster, witness or any other capacity related to the policyholder’s claim against Citizens. Acknowledged and Agreed to on the following date: , 20 , by: Name (print or type): Signature: Exhibit B - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Vendor Name Contract # 18-18-00310016-03 XX EXHIBIT C - INDIVIDUAL PROFILE & QUESTIONNAIRE Indicate with an "x" the License Type & Number: C: Name of Person Completing Form Form Completion Date Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Degree or Certification Earned Field of Study or Certification Title Please list education and certifications/licensing NOT listed above: Institution Name Years Completed Associate of Insurance Services (AIS) Certified Insurance Fraud Investigator (CIFI) Chartered Property Casualty Underwriter (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglary, Theft, Vandalism Sinkhole Water, Plumbing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit EXHIBIT C - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 INDIVIDUAL PROFILE & QUESTIONNAIRE WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EMPLOYER 2 List relevant work experience and job responsibilities here: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EMPLOYER 3 List relevant work experience and job responsibilities here: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EMPLOYER 4 List relevant work experience and job responsibilities here: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EXHIBIT C - INDIVIDUAL PROFILE & QUESTIONNAIRE POSITION-SPECIFIC QUESTIONNAIRE Number of times testifying at trial or evidentiary hearing? Estimate the number of interviews in last year? Estimate the number of interviews in the past 3 years? Number of EUOs attended in the last year? Number of hours of continuing education in the area of insurance investigations in the past year? Describe depth of experience conducting property investigations for the Cause of Loss / Matter Type indicated on Page 1. PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Describe any claims adjusting experience. PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Describe any specialized training, knowledge, skills or abilities that are relevant to property investigations in the State of Florida. PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Applicant Background Review Guide 5/28/2015 Felony Offenses Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Affray or Unlawful Assembly Not Eligible Eligible Not Eligible Not Eligible Assault Not Eligible Eligible Not Eligible Not Eligible Alcohol Possession by Person Under 21 Eligible Eligible Eligible Not Eligible Battery (Not Involving Domestic Violence) Not Eligible Eligible Not Eligible Not Eligible Battery Involving Domestic Violence Not Eligible Eligible Not Eligible Not Eligible Battery of or Threatening a Law Enforcement Officer or Public Official in the Performance of His/Her Duties Not Eligible Eligible Not Eligible Not Eligible Carrying a Concealed Weapon/Firearm Not Eligible Eligible Not Eligible Not Eligible Computer Crimes Not Eligible Eligible Not Eligible Not Eligible Contributing to the Delinquency or Dependency of a Child Not Eligible Criminal Mischief or Vandalism Not Eligible Eligible Not Eligible Not Eligible Cruelty to Animals Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Dealing in Stolen Property Valued at Less than $300 Over the Internet Not Eligible Eligible Not Eligible Not Eligible Discharging Firearm in Public Not Eligible Eligible Not Eligible Not Eligible Driving or Boating Under the Influence Not Eligible Eligible Not Eligible Not Eligible Driving While License Suspended or Revoked Not Eligible Eligible Not Eligible Not Eligible Failure to Pay Taxes Not Eligible Eligible Not Eligible Not Eligible No Driver’s License or Violation of License Restrictions Not Eligible Eligible Not Eligible Not Eligible Disorderly Conduct, Disorderly Intoxication, Breach of Peace, Disruption of School Board Meeting Eligible Eligible Eligible Not Eligible Failure to Control or Report Dangerous Fire Not Eligible Eligible Not Eligible Not Eligible False Personation or Impersonation of Law Enforcement Officer Not Eligible False Reports to Law Enforcement/ False Fire Alarms Not Eligible Firearms or Weapons Offenses Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Fireworks Possession or Discharge Eligible Eligible Eligible Not Eligible Fish and Game (Hunting) Violations Eligible Eligible Eligible Not Eligible Fraudulent Misrepresentation of Academic degree Not Eligible Gambling or Unlawful Betting Eligible Eligible Not Eligible Not Eligible Indecent Exposure Not Eligible Eligible Not Eligible Not Eligible Inhalation of Harmful Chemical Substances to Induce Intoxication Not Eligible Eligible Not Eligible Not Eligible Insurance Crimes (Unfair Claim Settlement Practices, Twisting, or Churning) Not Eligible Unnatural and Lascivious Acts Not Eligible Loitering or Prowling Not Eligible Eligible Not Eligible Not Eligible Obstruction by Disguised Person Not Eligible Eligible Not Eligible Not Eligible Perjury When Not in Official Proceeding Not Eligible Possession or Delivery of Under 20 Grams of Marijuana Not Eligible Eligible Not Eligible Not Eligible Possession of Drug Paraphernalia Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Prostitution Related Offenses Not Eligible Eligible Not Eligible Not Eligible Pornographic Display of Material to Minors Not Eligible Prescription Drug Offenses Not Eligible Eligible Not Eligible Not Eligible Reckless Driving or Reckless Operation of a Vessel Not Eligible Eligible Not Eligible Not Eligible Resisting an Officer (or Arrest) Without Violence Not Eligible Eligible Not Eligible Not Eligible Sale, Importation, or Distribution of Controlled Substances (drugs); or Possession for Sale, Importation or Distribution Not Eligible Eligible Not Eligible Not Eligible Stalking Not Eligible Tampering With Motor Vehicles or Trailers Not Eligible Eligible Not Eligible Not Eligible Theft, Petit Theft, or Retail Theft/ Shoplifting Not Eligible Trespass Not Eligible Eligible Not Eligible Not Eligible Unlawful Interception or Reception of Law Enforcement Frequencies Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Unlawful Placing, Throwing, or Discharging a Bomb Not Eligible Eligible Not Eligible Not Eligible Unlawful Reception of Cable Services Not Eligible Eligible Not Eligible Not Eligible Voyeurism Not Eligible Worthless Checks or Stopping Payment with Intent to Defraud of Less than $150 Not Eligible Eligible Not Eligible Not Eligible
Appears in 1 contract
Samples: Attachment J Agreement for Special Investigative Services
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I shall not at any time in the future represent a Citizens policyholder in a claim against Citizens for which I provided services or gained knowledge about as a employee or sub-contractor of Vendor. This would include acting as a consultant, public adjuster, witness or any other capacity related to the policyholder’s claim against Citizens. Acknowledged and Agreed to on the following date: , 20 , by: Name (print or type): Signature: Exhibit B - Contract between Citizens and Eagle Eye Investigative Solutions, Capinvad LLC d/b/a Capital Investigating Contract # 18-18-0031-03 06 Indicate with an "x" the License Type & Number: C: Name of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Degree or Certification Earned Field of Study or Certification Title Please list education and certifications/licensing NOT listed above: Institution Name Years Completed Associate of Insurance Services (AIS) Certified Insurance Fraud Investigator (CIFI) Chartered Property Casualty Underwriter (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglary, Theft, Vandalism Sinkhole Water, Plumbing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative Solutions, Capinvad LLC d/b/a Capital Investigating Contract # 18-18-0031-03 06 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:
Appears in 1 contract
Samples: Contingent Agreement for Special Investigative Services
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I shall not at any time in the future represent a Citizens policyholder in a claim against Citizens for which I provided services or gained knowledge about as a employee or sub-contractor of Vendor. This would include acting as a consultant, public adjuster, witness or any other capacity related to the policyholder’s claim against Citizens. Acknowledged and Agreed to on the following date: , 20 , by: Name (print or type): Signature: Exhibit B - Contract between Citizens and Eagle Eye Investigative SolutionsXxxxxxx & Associates, LLC Contract # 18-18-0031-03 08 Page 31 of 39 Indicate with an "x" the License Type & Number: C: Name of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Degree or Certification Earned Field of Study or Certification Title Please list education and certifications/licensing NOT listed above: Institution Name Years Completed Associate of Insurance Services (AIS) Certified Insurance Fraud Investigator (CIFI) Chartered Property Casualty Underwriter (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglary, Theft, Vandalism Sinkhole Water, Plumbing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative SolutionsXxxxxxx & Associates, LLC Contract # 18-18-0031-03 08 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:
Appears in 1 contract
Samples: Contingent Agreement for Special Investigative Services
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I am bound by the Prohibition of Future Representation and agree I shall not at any time in the future represent a Citizens policyholder Citizens’ Insured in a the insured’s claim against Citizens for which I provided claim-related services or gained knowledge about as a employee or sub-contractor of Vendoron Citizens’ behalf with respect to that same claim. This would include include, but not be limited to, acting as a consultant, public adjuster, witness adjuster or any other capacity related to the policyholderInsured’s claim against Citizens. Acknowledged and Agreed agreed to on the following date: , 20 , by: Name of Vendor: Name of employee or sub-contractor (print or type): SignatureSignature of employee or sub-contractor: Exhibit B - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 Indicate with an "x" Florida Department of Financial Services adjuster license number (if licensed): EXHIBIT D APPLICANT BACKGROUND REVIEW GUIDE 5/28/2015 Felony Offenses Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Affray or Unlawful Assembly Not Eligible Eligible Not Eligible Not Eligible Assault Not Eligible Eligible Not Eligible Not Eligible Alcohol Possession by Person Under 21 Eligible Eligible Eligible Not Eligible Battery (Not Involving Domestic Violence) Not Eligible Eligible Not Eligible Not Eligible Battery Involving Domestic Violence Not Eligible Eligible Not Eligible Not Eligible Battery of or Threatening a Law Enforcement Officer or Public Official in the License Type & Number: C: Name Performance of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go His/Her Duties Not Eligible Eligible Not Eligible Not Eligible Carrying a Concealed Weapon/Firearm Not Eligible Eligible Not Eligible Not Eligible Computer Crimes Not Eligible Eligible Not Eligible Not Eligible Contributing to the next lineDelinquency or Dependency of a Child Not Eligible Criminal Mischief or Vandalism Not Eligible Eligible Not Eligible Not Eligible Cruelty to Animals Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Dealing in Stolen Property Valued at Less than $300 Over the Internet Not Eligible Eligible Not Eligible Not Eligible Discharging Firearm in Public Not Eligible Eligible Not Eligible Not Eligible Driving or Boating Under the Influence Not Eligible Eligible Not Eligible Not Eligible Driving While License Suspended or Revoked Not Eligible Eligible Not Eligible Not Eligible Failure to Pay Taxes Not Eligible Eligible Not Eligible Not Eligible No Driver’s License or Violation of License Restrictions Not Eligible Eligible Not Eligible Not Eligible Disorderly Conduct, hold ALT Disorderly Intoxication, Breach of Peace, Disruption of School Board Meeting Eligible Eligible Eligible Not Eligible Failure to Control or Report Dangerous Fire Not Eligible Eligible Not Eligible Not Eligible False Personation or Impersonation of Law Enforcement Officer Not Eligible False Reports to Law Enforcement/ False Fire Alarms Not Eligible Firearms or Weapons Offenses Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Fireworks Possession or Discharge Eligible Eligible Eligible Not Eligible Fish and press ENTER. Degree Game (Hunting) Violations Eligible Eligible Eligible Not Eligible Fraudulent Misrepresentation of Academic degree Not Eligible Gambling or Certification Earned Field Unlawful Betting Eligible Eligible Not Eligible Not Eligible Indecent Exposure Not Eligible Eligible Not Eligible Not Eligible Inhalation of Study Harmful Chemical Substances to Induce Intoxication Not Eligible Eligible Not Eligible Not Eligible Insurance Crimes (Unfair Claim Settlement Practices, Twisting, or Certification Title Please list education Churning) Not Eligible Unnatural and certifications/licensing NOT listed above: Institution Name Lascivious Acts Not Eligible Loitering or Prowling Not Eligible Eligible Not Eligible Not Eligible Obstruction by Disguised Person Not Eligible Eligible Not Eligible Not Eligible Perjury When Not in Official Proceeding Not Eligible Possession or Delivery of Under 20 Grams of Marijuana Not Eligible Eligible Not Eligible Not Eligible Possession of Drug Paraphernalia Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Completed Associate Conviction of Insurance Services any Combination* of Three (AISor more) Certified Insurance Fraud Investigator Misdemeanor Offenses in Past 10 Years Prostitution Related Offenses Not Eligible Eligible Not Eligible Not Eligible Pornographic Display of Material to Minors Not Eligible Prescription Drug Offenses Not Eligible Eligible Not Eligible Not Eligible Reckless Driving or Reckless Operation of a Vessel Not Eligible Eligible Not Eligible Not Eligible Resisting an Officer (CIFIor Arrest) Chartered Property Casualty Underwriter Without Violence Not Eligible Eligible Not Eligible Not Eligible Sale, Importation, or Distribution of Controlled Substances (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglarydrugs); or Possession for Sale, Importation or Distribution Not Eligible Eligible Not Eligible Not Eligible Stalking Not Eligible Tampering With Motor Vehicles or Trailers Not Eligible Eligible Not Eligible Not Eligible Theft, Vandalism Sinkhole WaterPetit Theft, Plumbingor Retail Theft/ Shoplifting Not Eligible Trespass Not Eligible Eligible Not Eligible Not Eligible Unlawful Interception or Reception of Law Enforcement Frequencies Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Unlawful Placing, Pipe Breaks Weather Related Claims Throwing, or Discharging a Bomb Not Eligible Eligible Not Eligible Not Eligible Unlawful Reception of Cable Services Not Eligible Eligible Not Eligible Not Eligible Voyeurism Not Eligible Worthless Checks or Stopping Payment with Intent to Defraud of Less than $150 Not Eligible Eligible Not Eligible Not Eligible *Combination – a combination of any of the misdemeanor offenses listed on the review guide or other non–listed misdemeanors. EXHIBIT E COMPENSATION SCHEDULE SINKHOLE ENGINEERING SERVICES - PRICE FOR THREE (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # YEAR BASE TERM AND OPTIONAL TWO (2) YEAR RENEWAL PERIOD Service Price 1) Sinkhole Engineer Reports Position Description Price Unit Sr. Geologist $150.00 Per Hour Geologist $100.00 Per Hour Sr. Geotechnical Engineer $175.00 Per Hour Geotechnical Engineer $125.00 Per Hour Sr. Structural Engineer $175.00 Per Hour Structural Engineer $125.00 Per Hour Field Staff $75.00 Per Hour Service Description Price Unit Floor Evaluation Survey $500.00 Per Survey Geophysical Survey $1,200.00 Per Survey Boring Charge $25.00 Per Linear Foot Drafting $60.00 Per Hour Mobilization $5.00 Per Mile Report Preparation $100.00 Per Hour Retrieval of Investigations conducted Archival Files $50.00 Per File 2) Stabilization Monitoring Position Description Price Unit Sr. Geologist $140.00 Per Hour Geologist $90.00 Per Hour Sr. Geotechnical Engineer $150.00 Per Hour Geotechnical Engineer $110.00 Per Hour Sr. Structural Engineer $160.00 Per Hour Structural Engineer $110.00 Per Hour Field Staff $75.00 Per Hour Service Description Price Unit Report Prep $70.00 Per Hour 3) Peer Reviews Service Description Price Unit Peer Review $850.00 Per Review 4) Expert Services As defined in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:$300.00 Per Hour
Appears in 1 contract
Samples: Engineering Services
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I shall not at any time in the future represent a Citizens policyholder in a claim against Citizens for which I provided services or gained knowledge about as a employee or sub-contractor of Vendor. This would include acting as a consultant, public adjuster, witness or any other capacity related to the policyholder’s claim against Citizens. Acknowledged and Agreed to on the following date: , 20 , by: Name (print or type): Signature: Exhibit B - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Vendor Name Contract # 18-18-0031-03 Indicate with an "x" the License Type XX EXHIBIT C - INDIVIDUAL PROFILE & Number: C: QUESTIONNAIRE Name of Person Completing Form Form Completion Date Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Degree or Certification Earned Field EDUCATION / CERTIFICATIONS / LICENSING Indicate with an "x" the License Type & Number: C: Florida License: All Lines 620 Public Adjuster 320 Agent 220 Other Indicate with an "x" the industry designations / certifications held: Fraud Claims Law Associate (FCLA) Certified Insurance Fraud Investigator (CIFI) Associate of Study or Certification Title Insurance Services (AIS) Fraud Claims Law Specialist (FCLS) Chartered Property Casualty Underwriter (CPCU) Senior Claim Law Associate (SCLA) Associate in Claims (AIC) Please list education and certifications/licensing NOT listed above: Institution Name Years Completed Associate Field of Insurance Services Study or Certification Title Degree or Certification Earned EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Cause of Loss / Matter Type # of Investigations conducted in the Past 12 Months # of Investigations conducted in the Past 3 Years Proficiency Level Rating* (AISsupported on page 3) Certified Insurance Fraud Investigator (CIFI) Chartered Property Casualty Underwriter (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglary, Theft, Vandalism Sinkhole Water, Plumbing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit EXHIBIT C - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 INDIVIDUAL PROFILE & QUESTIONNAIRE WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EMPLOYER 2 List relevant work experience and job responsibilities here: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EMPLOYER 3 List relevant work experience and job responsibilities here: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EMPLOYER 4 List relevant work experience and job responsibilities here: 1. 2. Company Name Start Date 3. 4. Position Title End Date 5. Full Time 6. City, State Part Time 7. EXHIBIT C - INDIVIDUAL PROFILE & QUESTIONNAIRE POSITION-SPECIFIC QUESTIONNAIRE Number of times testifying at trial or evidentiary hearing? Estimate the number of interviews in last year? Estimate the number of interviews in the past 3 years? Number of XXXx attended in the last year? Number of hours of continuing education in the area of insurance investigations in the past year? Describe depth of experience conducting property investigations for the Cause of Loss / Matter Type indicated on Page 1. PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Describe any claims adjusting experience. PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Describe any specialized training, knowledge, skills or abilities that are relevant to property investigations in the State of Florida. PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Proficiency Level Rating Chart Experience Level Description
Appears in 1 contract
Samples: Attachment J Agreement for Special Investigative Services
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I am bound by the Prohibition of Future Representation and agree I shall not at any time in the future represent a Citizens policyholder Citizens’ Insured in a the insured’s claim against Citizens for which I provided claim-related services or gained knowledge about as a employee or sub-contractor of Vendoron Citizens’ behalf with respect to that same claim. This would include include, but not be limited to, acting as a consultant, public adjuster, witness adjuster or any other capacity related to the policyholderInsured’s claim against Citizens. Acknowledged Xxxxxxxxxxxx and Agreed agreed to on the following date: , 20 , by: Name of Vendor: Name of employee or sub-contractor (print or type): SignatureSignature of employee or sub-contractor: Exhibit Florida Department of Financial Services adjuster license number (if licensed): EXHIBIT B - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 Indicate with an "x" APPLICANT BACKGROUND REVIEW GUIDE 5/28/2015 Felony Offenses Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Affray or Unlawful Assembly Not Eligible Eligible Not Eligible Not Eligible Assault Not Eligible Eligible Not Eligible Not Eligible Alcohol Possession by Person Under 21 Eligible Eligible Eligible Not Eligible Battery (Not Involving Domestic Violence) Not Eligible Eligible Not Eligible Not Eligible Battery Involving Domestic Violence Not Eligible Eligible Not Eligible Not Eligible Battery of or Threatening a Law Enforcement Officer or Public Official in the License Type & Number: C: Name Performance of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go His/Her Duties Not Eligible Eligible Not Eligible Not Eligible Carrying a Concealed Weapon/Firearm Not Eligible Eligible Not Eligible Not Eligible Computer Crimes Not Eligible Eligible Not Eligible Not Eligible Contributing to the next lineDelinquency or Dependency of a Child Not Eligible Criminal Mischief or Vandalism Not Eligible Eligible Not Eligible Not Eligible Cruelty to Animals Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Dealing in Stolen Property Valued at Less than $300 Over the Internet Not Eligible Eligible Not Eligible Not Eligible Discharging Firearm in Public Not Eligible Eligible Not Eligible Not Eligible Driving or Boating Under the Influence Not Eligible Eligible Not Eligible Not Eligible Driving While License Suspended or Revoked Not Eligible Eligible Not Eligible Not Eligible Failure to Pay Taxes Not Eligible Eligible Not Eligible Not Eligible No Driver’s License or Violation of License Restrictions Not Eligible Eligible Not Eligible Not Eligible Disorderly Conduct, hold ALT Disorderly Intoxication, Breach of Peace, Disruption of School Board Meeting Eligible Eligible Eligible Not Eligible Failure to Control or Report Dangerous Fire Not Eligible Eligible Not Eligible Not Eligible False Personation or Impersonation of Law Enforcement Officer Not Eligible False Reports to Law Enforcement/ False Fire Alarms Not Eligible Firearms or Weapons Offenses Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Fireworks Possession or Discharge Eligible Eligible Eligible Not Eligible Fish and press ENTER. Degree Game (Hunting) Violations Eligible Eligible Eligible Not Eligible Fraudulent Misrepresentation of Academic degree Not Eligible Gambling or Certification Earned Field Unlawful Betting Eligible Eligible Not Eligible Not Eligible Indecent Exposure Not Eligible Eligible Not Eligible Not Eligible Inhalation of Study Harmful Chemical Substances to Induce Intoxication Not Eligible Eligible Not Eligible Not Eligible Insurance Crimes (Unfair Claim Settlement Practices, Twisting, or Certification Title Please list education Churning) Not Eligible Unnatural and certifications/licensing NOT listed above: Institution Name Lascivious Acts Not Eligible Loitering or Prowling Not Eligible Eligible Not Eligible Not Eligible Obstruction by Disguised Person Not Eligible Eligible Not Eligible Not Eligible Perjury When Not in Official Proceeding Not Eligible Possession or Delivery of Under 20 Grams of Marijuana Not Eligible Eligible Not Eligible Not Eligible Possession of Drug Paraphernalia Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Completed Associate Conviction of Insurance Services any Combination* of Three (AISor more) Certified Insurance Fraud Investigator Misdemeanor Offenses in Past 10 Years Prostitution Related Offenses Not Eligible Eligible Not Eligible Not Eligible Pornographic Display of Material to Minors Not Eligible Prescription Drug Offenses Not Eligible Eligible Not Eligible Not Eligible Reckless Driving or Reckless Operation of a Vessel Not Eligible Eligible Not Eligible Not Eligible Resisting an Officer (CIFIor Arrest) Chartered Property Casualty Underwriter Without Violence Not Eligible Eligible Not Eligible Not Eligible Sale, Importation, or Distribution of Controlled Substances (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglarydrugs); or Possession for Sale, Importation or Distribution Not Eligible Eligible Not Eligible Not Eligible Stalking Not Eligible Tampering With Motor Vehicles or Trailers Not Eligible Eligible Not Eligible Not Eligible Theft, Vandalism Sinkhole WaterPetit Theft, Plumbingor Retail Theft/ Shoplifting Not Eligible Trespass Not Eligible Eligible Not Eligible Not Eligible Unlawful Interception or Reception of Law Enforcement Frequencies Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Unlawful Placing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation Throwing, or Discharging a Bomb Not Eligible Eligible Not Eligible Not Eligible Unlawful Reception of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # Cable Services Not Eligible Eligible Not Eligible Not Eligible Voyeurism Not Eligible Worthless Checks or Stopping Payment with Intent to Defraud of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:Less than $150 Not Eligible Eligible Not Eligible Not Eligible
Appears in 1 contract
Samples: Attachment H Agreement
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I am bound by the Prohibition of Future Representation and agree I shall not at any time in the future represent a Citizens policyholder Citizens’ Insured in a the insured’s claim against Citizens for which I provided claim-related services or gained knowledge about as a employee or sub-contractor of Vendoron Citizens’ behalf with respect to that same claim. This would include include, but not be limited to, acting as a consultant, public adjuster, witness adjuster or any other capacity related to the policyholderInsured’s claim against Citizens. Acknowledged and Agreed agreed to on the following date: , 20 , by: Name of Vendor: Name of employee or sub-contractor (print or type): SignatureSignature of employee or sub-contractor: Exhibit Florida Department of Financial Services adjuster license number (if licensed): EXHIBIT B - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 Indicate with an "x" APPLICANT BACKGROUND REVIEW GUIDE 5/28/2015 Felony Offenses Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Affray or Unlawful Assembly Not Eligible Eligible Not Eligible Not Eligible Assault Not Eligible Eligible Not Eligible Not Eligible Alcohol Possession by Person Under 21 Eligible Eligible Eligible Not Eligible Battery (Not Involving Domestic Violence) Not Eligible Eligible Not Eligible Not Eligible Battery Involving Domestic Violence Not Eligible Eligible Not Eligible Not Eligible Battery of or Threatening a Law Enforcement Officer or Public Official in the License Type & Number: C: Name Performance of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go His/Her Duties Not Eligible Eligible Not Eligible Not Eligible Carrying a Concealed Weapon/Firearm Not Eligible Eligible Not Eligible Not Eligible Computer Crimes Not Eligible Eligible Not Eligible Not Eligible Contributing to the next lineDelinquency or Dependency of a Child Not Eligible Criminal Mischief or Vandalism Not Eligible Eligible Not Eligible Not Eligible Cruelty to Animals Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Dealing in Stolen Property Valued at Less than $300 Over the Internet Not Eligible Eligible Not Eligible Not Eligible Discharging Firearm in Public Not Eligible Eligible Not Eligible Not Eligible Driving or Boating Under the Influence Not Eligible Eligible Not Eligible Not Eligible Driving While License Suspended or Revoked Not Eligible Eligible Not Eligible Not Eligible Failure to Pay Taxes Not Eligible Eligible Not Eligible Not Eligible No Driver’s License or Violation of License Restrictions Not Eligible Eligible Not Eligible Not Eligible Disorderly Conduct, hold ALT Disorderly Intoxication, Breach of Peace, Disruption of School Board Meeting Eligible Eligible Eligible Not Eligible Failure to Control or Report Dangerous Fire Not Eligible Eligible Not Eligible Not Eligible False Personation or Impersonation of Law Enforcement Officer Not Eligible False Reports to Law Enforcement/ False Fire Alarms Not Eligible Firearms or Weapons Offenses Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Fireworks Possession or Discharge Eligible Eligible Eligible Not Eligible Fish and press ENTER. Degree Game (Hunting) Violations Eligible Eligible Eligible Not Eligible Fraudulent Misrepresentation of Academic degree Not Eligible Gambling or Certification Earned Field Unlawful Betting Eligible Eligible Not Eligible Not Eligible Indecent Exposure Not Eligible Eligible Not Eligible Not Eligible Inhalation of Study Harmful Chemical Substances to Induce Intoxication Not Eligible Eligible Not Eligible Not Eligible Insurance Crimes (Unfair Claim Settlement Practices, Twisting, or Certification Title Please list education Churning) Not Eligible Unnatural and certifications/licensing NOT listed above: Institution Name Lascivious Acts Not Eligible Loitering or Prowling Not Eligible Eligible Not Eligible Not Eligible Obstruction by Disguised Person Not Eligible Eligible Not Eligible Not Eligible Perjury When Not in Official Proceeding Not Eligible Possession or Delivery of Under 20 Grams of Marijuana Not Eligible Eligible Not Eligible Not Eligible Possession of Drug Paraphernalia Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Completed Associate Conviction of Insurance Services any Combination* of Three (AISor more) Certified Insurance Fraud Investigator Misdemeanor Offenses in Past 10 Years Prostitution Related Offenses Not Eligible Eligible Not Eligible Not Eligible Pornographic Display of Material to Minors Not Eligible Prescription Drug Offenses Not Eligible Eligible Not Eligible Not Eligible Reckless Driving or Reckless Operation of a Vessel Not Eligible Eligible Not Eligible Not Eligible Resisting an Officer (CIFIor Arrest) Chartered Property Casualty Underwriter Without Violence Not Eligible Eligible Not Eligible Not Eligible Sale, Importation, or Distribution of Controlled Substances (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglarydrugs); or Possession for Sale, Importation or Distribution Not Eligible Eligible Not Eligible Not Eligible Stalking Not Eligible Tampering With Motor Vehicles or Trailers Not Eligible Eligible Not Eligible Not Eligible Theft, Vandalism Sinkhole WaterPetit Theft, Plumbingor Retail Theft/ Shoplifting Not Eligible Trespass Not Eligible Eligible Not Eligible Not Eligible Unlawful Interception or Reception of Law Enforcement Frequencies Not Eligible Eligible Not Eligible Not Eligible Misdemeanor Offenses Automatic Disqualifier Conviction of Single Misdemeanor Offense Conviction of Single Misdemeanor Offense Within Past 24 Months Conviction of Single Misdemeanor Offense greater than 24 Months Conviction of any Combination* of Two (or more) Misdemeanor Offenses in Past 5 Years Conviction of any Combination* of Three (or more) Misdemeanor Offenses in Past 10 Years Unlawful Placing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation Throwing, or Discharging a Bomb Not Eligible Eligible Not Eligible Not Eligible Unlawful Reception of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # Cable Services Not Eligible Eligible Not Eligible Not Eligible Voyeurism Not Eligible Worthless Checks or Stopping Payment with Intent to Defraud of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative Solutions, LLC Contract # 18-18-0031-03 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:Less than $150 Not Eligible Eligible Not Eligible Not Eligible
Appears in 1 contract
Samples: Attachment H Agreement
PROHIBITION OF FUTURE REPRESENTATION. I understand that by my relationship with Vendor I shall not at any time in the future represent a Citizens policyholder in a claim against Citizens for which I provided services or gained knowledge about as a employee or sub-contractor of Vendor. This would include acting as a consultant, public adjuster, witness or any other capacity related to the policyholder’s claim against Citizens. Acknowledged and Agreed to on the following date: , 20 , by: Name (print or type): Signature: Exhibit B - Contract between Citizens and Eagle Eye Investigative SolutionsSpecialty Group, LLC Inc. Contract # 18-18-0031-03 05 Indicate with an "x" the License Type & Number: C: Name of Person Completing Form Form Completion Date Name Start Date Company Name Position Title County of Residence Please list the languages in which you are fluent (written and spoken): PLEASE NOTE: In order to go to the next line, hold ALT and press ENTER. Degree or Certification Earned Field of Study or Certification Title Please list education and certifications/licensing NOT listed above: Institution Name Years Completed Associate of Insurance Services (AIS) Certified Insurance Fraud Investigator (CIFI) Chartered Property Casualty Underwriter (CPCU) Associate in Claims (AIC) Fraud Claims Law Associate (FCLA) Fraud Claims Law Specialist (FCLS) Senior Claim Law Associate (SCLA) Indicate with an "x" the industry designations / certifications held: All Lines 620 Public Adjuster 320 Agent 220 Other Florida License: EDUCATION / CERTIFICATIONS / LICENSING Fire/ Arson Burglary, Theft, Vandalism Sinkhole Water, Plumbing, Pipe Breaks Weather Related Claims (Roof) Liability (Injury) HO Application/Underwriting Misrepresentation Surveillance Insurance Agent-related Investigation Other: Total: *For an explanation of Proficiency Level, please reference the "Proficiency Level Rating" tab. Proficiency Level Rating must match Attachment C. Proficiency Level Rating* (supported on page 3) # of Investigations conducted in the Past 3 Years # of Investigations conducted in the Past 12 Months Cause of Loss / Matter Type EXPERIENCE AS IT RELATES TO PROPERTY INSURANCE Exhibit C - Contract between Citizens and Eagle Eye Investigative SolutionsSpecialty Group, LLC Inc. Contract # 18-18-0031-03 05 WORK HISTORY EMPLOYER 1 List relevant work experience and job responsibilities here:
Appears in 1 contract
