I have been informed that this organization has a substance abuse and alcohol misuse policy in effect and that this policy allows the following: unannounced random testing, pre-employment, reasonable cause, post-accident, return to duty, and follow-up. I understand that complete copies of the policies are posted on the bulletin board and that I can review a complete copy of the Alcohol Misuse and Substance Abuse Policies by contacting the personnel department. I understand that it is my responsibility to read and become fully informed with regard to the alcohol misuse and substance abuse policy and the organizational drug program manager or third party administration group can answer that any questions I have concerning this policy.

I understand that as an applicant/adjuster I agree to willingly participate in the alcohol and substance drug testing program under the provisions set forth in the alcohol misuse and substance abuse policies. I also understand that these results are confidential but that results will be released to the company's Drug Program Manager, Medical Review Officer and/or their designee's. I understand that this information will otherwise be kept confidential and will not be released without my written consent or as it is otherwise permitted by the state law and drug and alcohol testing regulations.

Further, I understand that if I refuse to cooperate fully with management in its efforts to carry out the prescribed testing procedures as outlined in the alcohol and substance abuse policy or I have a reportable certified test result as prohibited by this policy I will be subject to discharge for insubordination (resistance of authority) or if as an applicant I fail to cooperate or have a reportable certified positive test result my application for employment will be denied and I will not be allowed to reapply with this organization

My signature below is given freely and without duress.