Online Producer Questionnaire - Personal Lines Division

    *Please make sure all the Personal Information listed above is correct.
    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.
    Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.
    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.