PERSONAL INFORMATION

Full Name: *
Date of Birth: *
Gender: *
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NPN #
License #
Effective Date
Expiration Date
Social Security Number
Address:
Email: *
Cell Phone: *
Alternate Phone:
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Other Languages:
Are you licensed in Life & Health and/or Property & Casualty? *

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JOB INFORMATION

Desired Position:
Date Available:
Other Position:

APPLICATION AGREEMENT

I certify that there are no willful misrepresentations, omissions or falsification of the information provided on this application of employment. I understand that initial and continued employment depends on the truth and accuracy of this information and any misrepresentation will result in denial or employment or immediate termination of employment regardless of when or how discovered. I agree to submit to a physical examination after an offer of employment has been made, which may include a drug screening for illegal drugs. I authorized the investigation of all matters which MP Insurance Solutions seems relevant to my qualifications for employment. I authorize MP Insurance Solutions to request and receive such information and release from all liability any persons or employers supplying it. I also release MP Insurance Solutions and its officers and representatives from all liability that might result from making the investigation.

APPLICATION OF EMPLOYMENT AGREEMENT: I understand that the employment relationship at MP Insurance Solutions is on an at-will basis and that if I am hired, I or MP Insurance Solutions man end the employment relationship at any time with or without cause with or without notice. I further understand that this provision may be modified only by the President/COO with a signed statement specifying period of employment.

Application Signature:
Today's Date:

CONFIDENTIALITY AGREEMENT

Please click the link below to read the agreement, and then make a selection.
Click to view Confidentiality Agreement
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UPLOAD DOCUMENTS

Please upload applicable documentation.
State Insurance License
E&O Insurance License
AHIP
AML
Resume
Social Security Card
Photo ID
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