Online Producers Personal Lines Questionnare

Do you currently hold a High School Diploma?*
Yes No

Name and Location of School*

GPA*

Did you attend College?*
Yes No

Name and Location of College*

Course Of Study*

Years Completed*

GPA*

Did you Graduate?*
Yes No

Degree / Diploma Attained*

Did you attend a University?*
Yes No

Name and Location of University*

Course Of Study*

Years Completed*

GPA*

Did you Graduate?*
Yes No

Degree / Diploma Attained*

Did you undergo through other special training skills gained from other means of education?*
Yes No

Please Specify

Do you have an Insurance License?*
Yes No

Please Specify*

Accomplishments / Awards

Introduce yourself in a short paragraph no more than 5 sentences.*

Please let us know how familiar are you and have experience in the fields below with 1 being little to no experience and 5 being very experienced.

Personal Lines Insurance* 1 2 3 4 5

Health Insurance* 1 2 3 4 5

Commercial Insurance* 1 2 3 4 5

Customer Service* 1 2 3 4 5

Marketing* 1 2 3 4 5

Sales* 1 2 3 4 5

Administration* 1 2 3 4 5

Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.

What is your current occupation status?* Full Time Part Time Unemployed Business Owner

Please specify reason for unemployment*

How many jobs have you undertook in the last 10 years?* None 1 2 3 more than 3

Company Name*

Company Address*

Company Phone Number*

Name of Supervisor*

Start Date of Employment*

End Date of Employment*

Starting Monthly Pay*

Ending Monthly Pay*

Job Title*

Short Description of your Previous Work*

Reason for Leaving*

Select the word that best describes you* Forceful Charming Easygoing Curious

Select the word that best describes you* Decisive Charming Optimistic Patient Restrained

Select the word that best describes you* Competitive Talkative Accomodating Precise

Select the word that best describes you* Directing Influencing Steady Cautious

Select the word that best describes you* Daring Enthusiastic Stabilizing Analytical

APPLICANT'S DIGITAL SIGNATURE

PLEASE READ AND UNDERSTAND THE STATEMENT BELOW BEFORE FINALIZING YOUR APPLICATION:

The information I have provided in this Application for Employment is true, correct, and complete. False, incomplete, or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination.

I authorize the employer to contact an obtain information about me from previous employers, educational institutions, and "references" I provided, and any other party necessary to verify the accuracy of information I disclosed in the application, a related employment resume or a personal interview. To assist in the processing of my application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations, or organizations who provide information for this purpose.

This application is not an employment agreement. If I accept an offer of employment, I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than an executive officer of the employer, has authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer.

Provide the following information as your digital signature.

Enter your Initials*

Enter your birth Month and Date*

Enter your Email Address*

Enter your Email Address for Verification Purposes*

Enter Today's Date*