Bolder Insurance Employment Application

Step 1 of 5

Employment
(Start with most recent employment and work backwards)
Employer
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment Start Date
Date Format: MM slash DD slash YYYY
Employment End Date
Date Format: MM slash DD slash YYYY
Ending Compensation
Date Format: MM slash DD slash YYYY
Reason for leaving
Describe work performed
Employer
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisors Name & Title
Employment Start Date
Date Format: MM slash DD slash YYYY
Employment End Date
Date Format: MM slash DD slash YYYY
Ending Compensation
Date Format: MM slash DD slash YYYY
Reason for leaving
Describe work performed
Employer
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisors Name & Title
Employment Start Date
Date Format: MM slash DD slash YYYY
Employment End Date
Date Format: MM slash DD slash YYYY
Ending Compensation
Date Format: MM slash DD slash YYYY
Reason for leaving
Describe work performed

References
Please include at least two business and one personal references.
Name
First Last
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Occupation
Relationship
Name
First Last
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Occupation
Relationship
Name
First Last
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Occupation
Relationship
Additional Experience or Qualifications
List any other experiences, skills or qualifications that you believe should be considered in evaluating your qualifications for employment.
Upload Resume'

Notification and Agreement
It is a Bolder Insurance 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 Bolder Insurance 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 Bolder Insurance I understand that Bolder Insurance retains the right to solely decide when such conflict exists. If employed, I agree to hold in strictest confidence any information concerning Bolder Insurance 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 Bolder Insurance and understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either Bolder Insurance or myself. I understand that no representative of Bolder Insurance 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 Bolder Insurance
I certify that all answers given by me are true, accurate and complete, 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.
Signed
Date
Date Format: MM slash DD slash YYYY

Step 1 of 5

Bolder Insurance Employment Application

Employment

Education

Licenses

Software

References

Additional Experience or Qualifications

Notification and Agreement