Name: Secure Insurance Group Ohio
Address: 4889 Sawmill Rd., Columbus, OH, 43235, US
Telephone: (614) 943-0500

Position Applied for:
Application Date:
MM slash DD slash YYYY
Personal Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Alternate Phone
Email
Alternate Email
Are you available to work:
- Full time?
- Part time?
If you are under 18 years of age, can you provide required proof of work eligibility?
- Yes
- No
- N/A
Do you or will you in the future require sponsorship for employment visa status?
- Yes
- No
Have you ever worked or submitted an application with this agency before?
- Yes
- No
If yes, when?
Do you have any friends or relatives employed by this company?
- Yes
- No
Are you currently employed?
- Yes
- No
Are you currently on layoff status and subject to recall?
- Yes
- No
May we contact your current employer?
- Yes
- No
Are you eligible to work in the United States? (Proof of eligibility will be required upon employment.)
- Yes
- No
Do you have a reliable means of transportation?
- Yes
- No
Have you ever been discharged from any employment or been asked to resign? (If yes, attach explanation.)
- Yes
- No
Are you bound by any agreement(s) (including signing a  non-competition, non-disclosure, non-solicitation, or  non-piracy agreement) that would limit your ability to work for the agency? (If yes, attach copy to this application.)
- Yes
- No
Are you able to perform all the essential functions of the job for which you are applying with or without reasonable accommodation?
- Yes
- No
If hired, would you be able to travel out of town/overnight?
- Yes
- No
If hired, would you be able to work overtime or weekends as needed?
- Yes
- No
If hired, would you be able to work overtime or weekends as needed?
- Yes
- No
Employment (start with most recent employment)
Employment 1
Employer Phone Address Start & End Date
Describe reason for leaving & work performed
Employment 2
Employer Phone Address Start & End Date
Describe reason for leaving & work performed
Employment 3
Employer Phone Address Start & End Date
Describe reason for leaving & work performed
Employment 4
Employer Phone Address Start & End Date
Describe reason for leaving & work performed
Education
School Name Address Grade Comlleted / Degrees Subjects Studied
List any seminars, classes, or other education not listed above which may help qualify you for this position.
Optional: List any professional, trade, business, or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability, gender orientation, or any other protected status.
Optional: List any languages other than English that you can speak, read, or write that may be of benefit to the position applied for.
Designations
(Check all that apply)
- CIC
- CPCU
- CLU
- ChFC
- CRM
- CISR
Other Designations
Licenses
P&C License
Yes or No State & License #
L&H License
Yes or No State & License #
Broker’s License
Yes or No State & License #
Series 6 or 7 License
Yes or No State & License #
Other Licenses
Describe State & License #
Other Licenses
Describe State & License #
If you have ever had an insurance license suspended or revoked, include details and explanation.
If you have ever had an insurance license suspended or revoked, include details and explanation.
Software
Microsoft Word
Skill Level (Low, Medium, High) Version
Microsoft Excel
Skill Level (Low, Medium, High) Version
Microsoft Outlook
Skill Level (Low, Medium, High) Version
Agency Management Software:
Software Name Skill Level (Low, Medium, High) Version
Other
Software Name Skill Level (Low, Medium, High) Version
Other
Software Name Skill Level (Low, Medium, High) Version
References
(Please include at least three professional/work related references and one  personal reference. Professional references should be prior supervisors or  managers directly familiar with your work.)
Reference 1
Name Address Phone
Reference 1 continued
Title/Company Relationship Email
Reference 2
Name Address Phone
Reference 2 continued
Title/Company Relationship Email
Reference 3
Name Address Phone
Reference 3 continued
Title/Company Relationship Email
Reference 4
Name Address Phone
Reference 4 continued
Title/Company Relationship Email
Additional Experience or Qualifications
List any other experience, skills, or qualifications that you believe should be considered in evaluating your qualifications for employment.
If hired, what value would you bring to our company?
Describe what you believe are the most unique features of your work history.
Describe what you believe are the most unique features of your work history.
Desired Salary Range:
(Please read before submitting.) It is Secure Insurance Group Ohio's policy to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status or sexual orientation, individuals with a disability, or any other characteristic protected by applicable Federal, State, or Local law.

I authorize the investigation of all statements and information contained in this application. I release from liability anyone supplying such information, and I also release Secure Insurance Group Ohio from all liability that might result from making an investigation.

If employed, I agree to not engage in any outside activity that would involve a material conflict of interest with, or could reflect adversely on Secure Insurance Group Ohio. I understand that Secure Insurance Group Ohio retains the right to solely decide when such a conflict exists.

If employed, I agree to hold in strictest confidence any information concerning Secure Insurance Group Ohio, its Insureds, and its Carriers that may come to my knowledge.

In consideration of my employment, if I am employed, I agree to conform to the employment policies of Secure Insurance Group Ohio, and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Secure Insurance Group Ohio or myself. I understand that no representative of Secure Insurance Group Ohio, other than the President, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

I understand that completion of this employment application does not guarantee that I have been employed by Secure Insurance Group Ohio. By signing this application, I indicate that I understand that this company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline up to and including termination.

I understand that if I am offered a position with this company, I may be given a pre-employment drug/alcohol test as a condition of employment. My refusal to submit to a drug/alcohol test in a timely manner, or my failure to pass such a test means that I will not be employed by this company without lawful and approved documentation of any such substance found in such a test. Negative test results are required as a condition of employment. Test results will be kept confidential.

I understand and agree that if I am employed, my employment will be at will, which means that the company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the company will respect my right to terminate my employment at any time with or without cause and with or without notice.

I authorize investigation into all statements and references contained in this application. Said investigation may include interviews with past employers, workers, and friends.

I understand that the company is under no obligation to hire me as the result of accepting this completed application.

I certify that all answers given by me are true, accurate, and complete pursuant to the penalty of perjury under the laws of this state. I certify that I have not knowingly withheld any information that might adversely affect my chances for employment. I understand that the falsification, misrepresentation, or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

Employer	Phone	Address	Start & End Date

School Name	Address	Grade Comlleted / Degrees	Subjects Studied

Employment Application

Personal Information

Employment (start with most recent employment)

Education

Designations

Licenses

Software

References

Additional Experience or Qualifications