MP New Agent Form

Your MPire awaits.

If you are interested in becoming an agent for MP Insurance, please complete the application form below.

Once we receive your application, we will review your information and then get in touch with you to discuss the position further.

If you have any questions, please contact our office at 855-731-8888 or email us at info@mpsurance.com.

    PERSONAL INFORMATION

    Full Name: *
    Date of Birth: *
    Gender: *
    MaleFemale
    NPN #
    License #
    Effective Date
    Expiration Date
    Social Security Number
    Address:

    Email: *
    Cell Phone: *
    Alternate Phone:
    Language(s):
    EnglishSpanishArabicRussianTagalogOther
    Other Languages:
    Are you licensed in Life & Health and/or Property & Casualty? *
    YesNoBoth

    JOB INFORMATION

    Desired Position:
    Date Available:
    Other Position:

    APPLICATION AGREEMENT

    I certify that there are no willful misrepresentations, omissions or falsification of the information provided on this application of employment. I understand that initial and continued employment depends on the truth and accuracy of this information and any misrepresentation will result in denial or employment or immediate termination of employment regardless of when or how discovered. I agree to submit to a physical examination after an offer of employment has been made, which may include a drug screening for illegal drugs. I authorized the investigation of all matters which MP Insurance Solutions seems relevant to my qualifications for employment. I authorize MP Insurance Solutions to request and receive such information and release from all liability any persons or employers supplying it. I also release MP Insurance Solutions and its officers and representatives from all liability that might result from making the investigation.

    APPLICATION OF EMPLOYMENT AGREEMENT: I understand that the employment relationship at MP Insurance Solutions is on an at-will basis and that if I am hired, I or MP Insurance Solutions man end the employment relationship at any time with or without cause with or without notice. I further understand that this provision may be modified only by the President/COO with a signed statement specifying period of employment.

    Application Signature:
    [signature* applicant-signature 450x160]
    Today's Date:

    CONFIDENTIALITY AGREEMENT

    Please click the link below to read the agreement, and then make a selection.
    Click to view Confidentiality Agreement
    I AgreeI Disagree

    UPLOAD DOCUMENTS

    Please upload applicable documentation.
    State Insurance License
    E&O Insurance License
    AHIP
    AML
    Resume
    Social Security Card
    Photo ID
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