Employment Application

Eaglemind Insurance Agency Employment Application

All steps must be completed. Application is not completed until submitted.

Please enter your complete information for identification verification purposes

Please Enter your full Social Security Number for Background Check

Applicant's Personal/Job Information

License Background Questions

Resume Upload

  • Employment Application Disclosure
  • Contact Information
  • Applicant's Personal/Job Information
  • License Background Questions
  • Resume Upload

Eaglemind Insurance Agency is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.


Please note: You must be able to pass a background Check in order to be appointed with the carriers we represent

Social Security Number

First Name

Middle Name(If none, Enter

Last Name

Phone Number

Current Address

Positions and Openings

Which position(s) are you interested in?

How did you hear about this position?

Type your response here

What days and times are you available for work?

On what date can you start working if you are hired?

Are you available to work during or around these hours? 9AM TO 5PM (M-F) AND/OR SAT: 10AM TO 2PM? You don't have to work all these hours but be available to answer phones, enroll clients or respond to client inquiries during peak hours within above hours.

Have you ever applied to or worked for Eaglemind Insurance Agency before?

If Yes, when?

Do you have any friends, relatives, or acquaintances working for Eaglemind Insurance Agency

If yes, state name and relationship

Are you 18 years of age or older?

Are you a U.S. citizen or approved to work in the United States?

What document can you provide as proof of citizenship or legal status?

Do you have any condition which would legally require job accommodations? If yes, please describe accommodations required below.

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case.

Job Skills/Qualifications: Please list below the skills and qualifications you possess for the position for which you are applying

Education and Training: Do you have a high school diploma or any degree? If so please list

Previous Employment: Name and address of Employer/Contractor

Previous Employment: Start Date

Previous Employment: End Date ( Leave Blank if still with this Employer/Contractor

Previous Employment: Job Title

Previous Employment: Supervisor Name

These are questions related to your license

Do you currently have an Active Insurance License?

If yes, what kind of Insurance License do you currently have?

If no, do you plan or desire to obtain your insurance license?

AT-WILL EMPLOYMENT: The relationship between you and the Eaglemind Insurance Agency is referred to as

By typing my name below, I certify the above statements to be true and correct to the best of my knowledge, and that this information can be used for the purpose of processing my job application and or to verify my identity or complete my background check.

Resume Upload

Do you have resume to upload?

Max. size: 100.0 MB