• Address
  • Email address
  • Marital status
  • Person(s) to contact in the case of an emergency


  • Date you can start?
  • Employment desired


  • Education and Training
     School Name and Location of SchoolCourse of StudyNo. Years CompletedDid you Graduate?Degree or Diploma
    License or Certificate Training
    Other Special Training

EMPLOYMENT HISTORY (List below last four employers, starting with last one first.)

  • Employment Information (At least one employment)
    • Employed (month/year)
    • Address
    • Phone #


Have you ever been arrested, indicted or summoned into court as a defendant in a criminal proceeding? Or convicted? fined or imprisoned for the violation of any law (excluding minor traffic violations)? If yes, explain.

No Yes

REFERENCES(Do not list relatives or former Employers)

  • References (At least one reference)
      NameAddressPhone #Years KnownOccupation

In exchange for the consideration of my job application by NAGICO Insurances (hereinafter called “the Company”), I agree that:

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts is cause for dismissal at any time without previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I further understand that my employment with the Company shall be probationary for a period of two (2) months, and further that any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.