Employment Application

  • Date Format: MM slash DD slash YYYY
  • Personal Information

  • Employment (start with most recent employment)

  • EmployerPhoneAddressStart & End Date
  • EmployerPhoneAddressStart & End Date
  • EmployerPhoneAddressStart & End Date
  • EmployerPhoneAddressStart & End Date 
  • Education

  • School NameAddressGrade Comlleted / DegreesSubjects Studied 
  • Designations

  • Licenses

  • Yes or NoState & License #
  • Yes or NoState & License #
  • Yes or NoState & License #
  • Yes or NoState & License #
  • DescribeState & License #
  • DescribeState & License #
  • Software

  • Skill Level (Low, Medium, High)Version
  • Skill Level (Low, Medium, High)Version
  • Skill Level (Low, Medium, High)Version
  • Software NameSkill Level (Low, Medium, High)Version
  • Software NameSkill Level (Low, Medium, High)Version
  • Software NameSkill 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.)
  • NameAddressPhone
  • Title/CompanyRelationshipEmail
  • NameAddressPhone
  • Title/CompanyRelationshipEmail
  • NameAddressPhone
  • Title/CompanyRelationshipEmail
  • NameAddressPhone
  • Title/CompanyRelationshipEmail
  • Additional Experience or Qualifications

  • (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.