Exhibit A
Criminal Background Check
This form is to be completed by individuals who are not employed by Progressive Direct Insurance Company or its
affiliates (collectively referred to as “Progressive”) and who wish to take college courses being offered at a
Progressive facility. These individuals will typically not be escorted by Progressive employees while on site.
Progressive has a corporate policy of not permitting unescorted individuals who have been convicted of a
misdemeanor involving dishonesty, breach of trust or violence within the past five years, or who have ever been
convicted of a felony, to be on its premises. In furtherance of this policy, Progressive will attempt to obtain and use
information about you from “consumer reports.” A “consumer report” for this purpose is defined as any written,
oral or other communication of any information by a consumer reporting agency bearing on a consumer’s character,
general reputation, personal characteristics, or mode of living, which is used or collected for the purpose of serving
as a factor in establishing the consumer’s eligibility to be on Progressive’s premises without being escorted by a
Progressive employee.
If Progressive takes an adverse action (i.e. refuses to permit you to take college courses at its facilities) based on
information in a consumer report about you, then Progressive will notify you of the adverse action and identify the
consumer reporting agency that furnished the report. For 60 days following receipt of the notice, you may obtain a
free copy of the consumer report and dispute with the consumer reporting agency the accuracy or completeness of
any information in it. You are also free to contact the Federal Trade Commission about your rights under the Fair
Credit Reporting Act (“FCRA”).
By signing below, you are instructing the consumer reporting agency to furnish Progressive with consumer
reports about you for the purpose described above.
You have the right to request a copy of any consumer reports obtained by Progressive about you. Check this
box if you wish to receive a copy of the consumer reports. ❏ [Note: If you check this box, Progressive will
request the consumer reporting agency to mail copies of any consumer reports directly to you.]
Printed Name
Date
Social Security Number
(If you do not have a SS#, please write “none”)
_____________
Date of Birth
Home Phone Number
___________________________________________
Other names (including maiden name) if applicable
Current Address (include street, city, state and zip code):
________________________________________________
Signature
Please answer this information completely:
All the locations you have lived
All the locations you have
during your adult lifetime (city &
worked during your adult
state only)
lifetime (city & state only)
___________________________
CSU ID Number
Location of any high schools,
colleges or graduate schools you
may have attended (city & state
only)
The above chart must be completed in order for the consumer report to be generated.
Exhibit C
WAIVER AND RELEASE
I am planning to attend classes provided by Cleveland State University (“CSU”) on property
owned by The Progressive Corporation and/or its subsidiaries or affiliates, herein collectively
referred to as “Progressive.” I understand that there are risks of negligent acts and/or omissions
that may result in bodily injury, death and or property damage on the premises of this business. I
desire to release Progressive and its employees, officers, directors and agents and Cleveland
State University and its employees, officers, directors and agents from all claims in relation to
such use.
I hereby irrevocably waive any and all possible causes of actions against Progressive and its
employees, officers, directors, agents, and Cleveland State and its employees, officers, directors,
and agents in connections with any injury I may receive in connection with participation in this
CSU program at Progressive. I likewise irrevocably waive, to the extent legally possible, any
such claims for such injury brought by any relative or personal representative of mine.
The background check requires you to pay a $30 fee in check form payable to Progressive
Direct Insurance Company. Please return the completed forms and check to the Business
Advising Office in BU 219.
_____________________________
Signature
_____________________________
Printed Name
_____________________________
Date
Felony Questionnaire
1.
The federal Violent Crime Control and Law Enforcement Act of 1994 (the “Act”) requires that no
person who has been convicted of a felony involving “dishonesty” or “a breach of trust” participate in the
“business of insurance.” Criminal penalties for violations of the Act apply to you, your employer and
Progressive, and therefore, as a condition of your being permitted to work at Progressive, or with
Progressive confidential documents, you are required to answer the following question:
Have you ever been convicted of a felony involving “dishonesty” or “a breach of trust”?
“Yes” or “No” or “Not Sure”
2.
Progressive, as a matter of its business policy, will not permit people to work at Progressive or
with Progressive confidential documents who have been convicted of any felony.
Have you ever been convicted of any other felony?
“Yes” or “No” or “Not Sure”
3.
Progressive, as a matter of its business policy, will not permit people to work at Progressive or
with Progressive confidential documents who have been convicted of a misdemeanor involving
“dishonesty” or “a breach of trust” or violence within the past five years.
During the last five years have you been convicted of any misdemeanor involving “dishonesty” or “a
breach of trust” or violence?
“Yes” or “No” or “Not Sure”
If you answered “Yes” or “Not Sure,” to any of these questions, please give a brief explanation, including
type of offense, date and location (city or county and state).
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Print Name: __________________________________ SSN (last four digits only): ________________
Please note that by signing this document you are giving permission to furnish this document to
Progressive.
_____________________________________________________________________________________
Signature
Date