Wilhoit Insurance Employment Application
Complete this one-column application, including eligibility, licensing, and your statement, then submit for review.
This employment opportunity is with a State Farm Agent, not with State Farm Insurance Companies and requires the successful completion of licensing requirements to solicit and service State Farm products.
Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Street Address
City
State
ZIP Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Position Desired
*
Date Available to Begin
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employment Type Desired
Full Time
Part Time
Temporary
Days and Hours Available
Desired Compensation
Employment Eligibility and Availability
Legally authorized to work in the United States?
*
Yes
No
Will you now or in the future require employment authorization sponsorship?
*
Yes
No
Can you perform the essential duties of the position with or without reasonable accommodation?
*
Yes
No
Willing to work occasional evenings or weekends when business needs require?
Yes
No
Have you previously worked in a State Farm agent’s office?
Yes
No
Which State Farm agent’s office did you work in, and when?
Insurance Licensing
Current insurance licenses
*
Property & Casualty
Life & Health
Securities
Not currently licensed
Licensed states
License numbers
License expiration dates
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are your licenses active and in good standing?
*
Yes
No
Not applicable
If not currently licensed, are you willing to complete required licensing?
Yes
No
Not applicable
Insurance designations, securities registrations, or relevant certifications
Education and Training
Education Entry
Relevant Coursework
Training and Certifications
Professional Development
Awards and Honors
Additional Education Details 1
Additional Education Details 2
Additional Education Details 3
Additional Education Details 4
Additional Education Details 5
Additional Education Details 6
Additional Education Details 7
Additional Education Details 8
Skills and Qualifications
Skills and Qualifications
Customer service
Sales
Insurance service
Claims support
Office administration
Phone systems
Social media
Community outreach
Microsoft Office
CRM/agency systems
Bookkeeping
Bilingual
Other
Software, agency systems, and technical skills
Languages spoken and proficiency
Describe experience that makes you a strong candidate
*
Professional memberships, community involvement, or other job-related information
Employment History
You may attach a résumé, but please complete this Employment History section.
Employer 1 Name
*
Employer 1 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer 1 Address / City / State
Employer 1 Supervisor Name
Employer 1 Supervisor Title
Employer 1 Job Title
*
Employer 1 Dates Employed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employer 1 Starting Pay
Employer 1 Ending Pay
Employer 1 Primary Duties and Accomplishments
Employer 1 Reason for Leaving
May Wilhoit Insurance Contact Employer 1?
*
Yes
No
Only after an interview
Employer 2 Name
Employer 2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer 2 Address / City / State
Employer 2 Supervisor Name
Employer 2 Supervisor Title
Employer 2 Job Title
Employer 2 Dates Employed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employer 2 Starting Pay
Employer 2 Ending Pay
Employer 2 Primary Duties and Accomplishments
Employer 2 Reason for Leaving
May Wilhoit Insurance Contact Employer 2?
Yes
No
Only after an interview
Employer 3 Name
Employer 3 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer 3 Address / City / State
Employer 3 Supervisor Name
Employer 3 Supervisor Title
Professional References
Reference 1 Name
*
First Name
Middle Name
Last Name
Reference 1 Relationship / Organization
*
Reference 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1 Email
*
example@example.com
Reference 2 Name
*
First Name
Middle Name
Last Name
Reference 2 Relationship / Organization
*
Reference 2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 Email
*
example@example.com
Reference 3 Name
*
First Name
Middle Name
Last Name
Reference 3 Relationship / Organization
*
Reference 3 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3 Email
*
example@example.com
Applicant Statement and Authorization
Applicant Statement
I agree to the applicant statement above
*
I Agree
Applicant Electronic Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
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