MP Agent Form

Fill this out and join the MPire


Full Name: *
Date of Birth: *
Gender: *
License #
Effective Date
Expiration Date
Social Security Number
Email: *
Cell Phone: *
Alternate Phone:
Other Languages:
Are you licensed in Life & Health and/or Property & Casualty? *



Desired Position:
Date Available:
Other Position:


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:
Today's Date:


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


Please upload applicable documentation.
State Insurance License
E&O Insurance License
Social Security Card
Photo ID
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About MP Insurance

MP Insurance Solutions was formed in 1995 as a grass roots program that reached out to the local communities to provide Health Insurance for seniors. It has grown since that time to become a full service agency.

We specialize in all lines of Health Insurance and Health Insurance Management. MP Insurance Solutions is supported by a multi lingual staff that is driven by the one on one relationships with its clients.

Our Mission

At MP Insurance, our mission is very clear cut. We go over and beyond to provide a an all encompassing insurance selection toolkit for each of our clients. From start to finish, we exhaust all effort to provide an unparalleled insurance experience that empowers the individual or group with freedom of choice.

Our Location

32395 Clinton Kieth Rd A205
Wildomar, CA 92595