Berkshire Hathaway Homestate Companies

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Application For Employment

Claims Professional Trainee - San Diego

San Diego, CA

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Personal Information: First Name

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Oak River Insurance Company: OAK RIVER INSURANCE COMPANY IS AN EQUAL OPPORTUNITY EMPLOYER DEDICATED TO NON-DISCRIMINATION IN EMPLOYMENT. OAK RIVER INSURANCE COMPANY, SELECTS THE BEST QUALIFIED INDIVIDUAL FOR THE JOB BASED ON JOB-RELATED QUALIFICATIONS REGARDLESS OF GENDER, RACE, COLOR, RELIGION, AGE, CITIZENSHIP, SEXUAL ORIENTATION, GENDER IDENTITY, GENDER EXPRESSION, MARITAL STATUS, PREGNANCY, NATIONAL ORIGIN, ANCESTRY, PHYSICAL OR MENTAL DISABILITY, OR CONDITION, OR ANY OTHER STATUS PROTECTED BY APPLICABLE LAW.

Completing this Application: Please fill out all fields as completely and accurately as possible. The information you provide in your application will help us make important decisions about your qualifications for this position.

Background Information: Address

Address #2

City

State

Zip Code

Home Tel. No:

Are you at least 18 years of age?

(If you are under 18, hire is subject to verification that you are of minimum legal age to work)

If you are hired, can you present evidence of your legal right to live and work in this country?

(1) Have you ever been convicted of a felony?

(2) Additionally, all licensed individuals must verify whether or not they have been convicted of a misdemeanor that would preclude them from obtaining or retaining a license.

If yes, state nature of the crime(s), when and where convicted and disposition. (A conviction does not automatically disqualify you from employment.)

A refusal to verify or a 'yes' answer to either (1) or (2) of the above questions may prohibit the Company from hiring the applicant due the requirements imposed upon the Company by the Violent Crimes Control and Law Enforcement Act and other applicable state statutes and contractual requirements which prohibit persons convicted of certain crimes from working in the business of insurance, or from obtaining a required license. Should the status of your answer to questions (1) or (2) change after hiring or at any time during your employment with the Company, you are required to immediately advise the Human Resources Department. If we learn of information that reasonably demonstrates a 'yes' response to (1) or (2), and such information was not disclosed to us, your employment will be immediately terminated.

No applicant will be denied employment solely on the grounds of conviction of a criminal offense except to the extent necessary to obtain a necessary license or to comply with The Violent Crime Control and Law Enforcement Act of 1994, which prohibits the employment by an insurance company of persons convicted of certain crimes, unless a waiver is obtained. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered to the extent permitted by law.

Are you able to perform the essential functions of the position applied for, either with or without an accommodation?

If no, please explain:

How did you hear about this job?

Please specify, if applicable:

Background Information: Date Available for Employment:

Do you prefer:

If part-time, specify days and hours:

Are you employed now?

If so, may we contact your present employer?

What wage/salary do you expect?

Have you ever worked for Oak River Insurance or any other Berkshire Hathaway, Inc. company before?

If yes, name company:

Dates (From-To):

Education: Name and Address of High School:

# of Years Completed:

Year of Graduation:

Name and Address of College/University:

# of Years Completed:

Year of Graduation:

Major Subject:

Degree Earned:

Name and Address of Graduate or Technical:

# of Years Completed:

Year of Graduation:

Major Subject:

Degree Earned:

Additional Training/Skills, Experience, Special Achievements, Certificates, etc. relevant to position:

Have you served in the United States Armed Forces?

Branch:

Reserve Status:

Special Training:

Employment History: List below present and past employers beginning with the most recent:

Name and Address of Employer:

From (MM/YY):

To (MM/YY):

Initial Position Title and Duties:

Final Position Title and Duties:

Supervisor:

Telephone Number:

Starting Salary:

Ending Salary:

Reason for Leaving:

Name and Address of Employer:

From (MM/YY):

To (MM/YY):

Initial Position Title and Duties:

Final Position Title and Duties:

Supervisor:

Telephone Number:

Starting Salary:

Ending Salary:

Reason for Leaving:

Name and Address of Employer:

From (MM/YY):

To (MM/YY):

Initial Position Title and Duties:

Final Position Title and Duties:

Supervisor:

Telephone Number:

Starting Salary:

Ending Salary:

Reason for Leaving:

Name and Address of Employer:

From (MM/YY):

To (MM/YY):

Initial Position Title and Duties:

Final Position Title and Duties:

Supervisor:

Telephone Number:

Starting Salary:

Ending Salary:

Reason for Leaving:

AGREEMENT OF APPLICANT CERTIFICATION, AUTHORIZATIONS AND UNDERSTANDING OF EMPLOYMENT RELATIONSHIP: I hereby state that all the information that I provided on this Application or any other document submitted in connection with my employment, and in any interview, are true and correct. I have withheld nothing that would, if disclosed, affect this Application unfavorably. I understand that if I am employed and any information is later found to false in any respect or if I have omitted material information, I may be dismissed. I understand that if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States.

VOLUNTARY AGREEMENT TO ARBITRATE

You and the Company voluntarily and explicitly agree that any dispute, in any way related to your employment or prospective employment with this Company, which the parties are unable to resolve through direct discussion, regardless of the kind or type of dispute, shall be submitted exclusively to final and binding arbitration, except as prohibited by law. Likewise, you agree to waive any right to participate in class-wide adjudication of any dispute, and instead agree to submit your claim(s) to arbitration on an individual basis. The arbitration shall be conducted pursuant to the then current employment dispute resolution rules of the American Arbitration Association. To exercise a party's rights under this section, the moving party must reduce to writing the details of any dispute and serve it upon the other party. Any failure to request arbitration in a timely manner based on applicable California law shall constitute a waiver of all rights to raise any claims in any forum rising out of any dispute that was subject to arbitration.

The parties shall agree on a single arbitrator who shall take evidence and issue a written award. If the parties cannot agree within thirty (30) calendar days of the written notification of a dispute as specified above, an arbitrator shall be chosen by the parties by assembling a list of five (5) arbitrators. The parties shall select the arbitrator by alternately striking names from the list. The moving party shall strike the first name. This process shall be completed within forty (40) calendar days of the date the written request was served on the opposing party and/or the subsequent date arbitration is ordered by a court, whichever is sooner.

The parties voluntarily agree that arbitration shall be the exclusive, final and binding remedy for any and all disputes, except as provided above, between the partied hereto. The arbitrator shall only be authorized to exercise the power specifically enumerated in this Agreement and to decide the dispute(s) in accordance with the governing principles of law and equity. The arbitrator shall have no authority to alter, amend, or modify the terms of this Agreement. Should any party fail to appear or participate in the arbitration proceedings, the arbitrator may make a decision based on the evidence presented in the proceedings by the appearing party to the dispute. The arbitrator shall issue a written award within sixty (60) calendar days of the date the matter is submitted.

Judgment on the arbitration award may be entered in any court of competent jurisdiction. The adjudication of all disputes shall take place in the city of San Francisco and county of San Francisco unless the partied agree otherwise in writing. The Company shall pay all costs associated with the arbitration, except that each party shall bear its own expense for counsel and witness fees. This section does not limit the Company's 'at-will' employment policy.

I understand that by agreeing to this binding arbitration provision, both the Company and I voluntarily surrender my rights to civil litigation, and a trial by jury and any associated rights of appeal. My signature hereon confirms my voluntary agreement to this provision and further confirms that I have read and understood the contents of this Agreement.

If you have any questions regarding this statement, please ask a Company representative before signing.

AT WILL EMPLOYMENT

If hired, I agree as follows: My employment with the Company is terminable at will, is for no definite period, and my employment may be terminated by the Company or me at any time and for any reason whatsoever, with or without good cause. No implied, oral or written agreements contrary to the express language of this Agreement are valid unless they are in writing signed by the President of the Company. No supervisor or representative of the Company, other than the President of the Company, has any authority to make any agreements to the foregoing. This Agreement is the entire agreement between the Company and the employee regarding the right of Company or employee to terminate employment, and this Agreement takes the place of all prior agreements, representations, and understandings of the employee and the Company.

I have read and agree to this disclaimer

Applicant Signature

Date

Comments

U.S. Equal Employment Opportunity/Affirmative Action Information
Individuals seeking employment are considered without regards to race, color, religion, national origin, age, sex, marital status, ancestry, physical or mental disability, veteran status, or sexual orientation. You are being given the opportunity to provide the following information in order to help us comply with federal and state Equal Employment Opportunity/Affirmative Action record keeping, reporting, and other legal requirements.

Please Note: Completion of this form is voluntary
Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file.

Gender:

Male

Female

Decline to Self-Identify

Ethnicity/Race:

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Declined to Self-Identify

Veteran Status:

Veteran

Recently Separated Veteran

Armed Forces Service Medal Veteran

Other Protected Veteran

Not a Veteran

Decline to Self-Identify

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