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42
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1
Applying for Position
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Any Position
Personal Risk Advisor- Michigan City
Benefits Customer Service Representative - Any location
Commercial Lines Client Service Advisor - Michigan City
Personal Lines Client Service Representative - Michigan City
Commercial Lines Client Service Representative - Valparaiso
Employee Benefits Advisor - Crown Point, Merrillville, or Portage
Medicare Customer Service Advisor - Hobart
Medicare Customer Service Representative - Any Location
Please Select
Any Position
Personal Risk Advisor- Michigan City
Benefits Customer Service Representative - Any location
Commercial Lines Client Service Advisor - Michigan City
Personal Lines Client Service Representative - Michigan City
Commercial Lines Client Service Representative - Valparaiso
Employee Benefits Advisor - Crown Point, Merrillville, or Portage
Medicare Customer Service Advisor - Hobart
Medicare Customer Service Representative - Any Location
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2
Full Name
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First Name
Middle Name
Last Name
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3
Current Address
*
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Email Address
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johndoe@example.com
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5
Phone Number
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Area Code
Phone Number
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6
Are you 18 years of age or older?
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YES
NO
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7
If you are under 18 years of age, can you provide required proof of your eligibility to work?
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YES
NO
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8
Have you ever filed an application with us before?
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YES
NO
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9
When did you last apply to work with us?
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-
Date
Month
Day
Year
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10
Have you ever been employed with us before?
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YES
NO
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11
When were you previously employed with us?
*
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-
Date
Month
Day
Year
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12
Do any of your friends or relatives, other than spouse, work here?
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YES
NO
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13
Are you currently employed?
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YES
NO
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14
May we contact your current employer?
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YES
NO
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15
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
*
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Proof of citizenship or immigration status will be required upon employment.
YES
NO
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16
What date are you available to start work?
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-
Date
Month
Day
Year
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17
Are you available to work full-time?
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YES
NO
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18
If no, please describe your desired work schedule.
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19
What is your desired salary range?
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20
Are you currently on lay-off status and subject to recall?
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YES
NO
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21
Can you travel if the job requires it?
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YES
NO
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22
What is the highest level of education completed?
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High School
Undergraduate College
Graduate School
Other
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23
Education History
*
This field is required.
Please enter the details for the High School you attended.
Name of School
Address
City, State, Zip
Diploma / Degree
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24
Education History
*
This field is required.
Please enter the details for the Undergraduate College or University you attended.
Name of School
Address
City, State, Zip
Course of Study
Degree
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25
Education History
*
This field is required.
Please enter the details for the Graduate school you attended.
Name of School
Address
City, State, Zip
Course of Study
Degree
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26
If other, please explain.
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27
Employment History
*
This field is required.
Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.
Employer
Job Title
Address, City, State, Zip Code
Phone Number
Start Date - End Date
Hourly Rate / Salary
Supervisor Name
Reason for Leaving
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28
Employment History
*
This field is required.
Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.
Employer
Job Title
Address, City, State, Zip Code
Phone Number
Start Date - End Date
Hourly Rate / Salary
Supervisor Name
Reason for Leaving
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29
Employment History
*
This field is required.
Start with your present or or last job. Included any job-related military services assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.
Employer
Job Title
Address, City, State, Zip Code
Phone Number
Start Date - End Date
Hourly Rate / Salary
Supervisor Name
Reason for Leaving
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30
Describe any specialized training, apprenticeships, skills, and extra-curricular activities.
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31
List professional, trade, business or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.
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32
Please share any additional information you feel may be helpful to us in considering your application.
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33
Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation?
YES
NO
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34
Reference #1 - Do not list relatives.
*
This field is required.
Name
Phone
Title (if applicable)
Company (if applicable)
Address
Relationship
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35
Reference #2 - Do not list relatives.
*
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Name
Phone
Title (if applicable)
Company (if applicable)
Address
Relationship
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36
Reference #3 - Do not list relatives.
*
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Name
Phone
Title (if applicable)
Company (if applicable)
Address
Relationship
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37
How did you hear about this position?
*
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Online Search (i.e. Indeed)
Social Media (i.e. Facebook, LinkedIn)
Career Fair
Chamber of Commerce
Referral
Other
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38
If you were referred, by who?
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39
Upload Resume
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40
Applicant's Statement:
I certify that answers given herein are true and complete. I authorized investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
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Clear
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41
Please verify that you are human
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42
This is a fill in the
blanks
field. Please add appropriate
blank
fields and text.
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