Job Application

The Motorists Insurance Group

Employment Application

The Motorists Insurance Group is a multi-company organization. Reference to the "company" includes Motorists Mutual Insurance Company, Motorists Life Insurance Company, MICO Insurance Company, Broad Street Brokerage, Motorists Service Corporation, Wilson Mutual Insurance Company and Iowa Mutual Insurance Company.

THE COMPANY OFFERS EQUAL EMPLOYMENT OPPORTUNTITIES without regard to race, color, religion, age, sex, national origin, disability, military or veteran's status, or any other basis protected by federal, state or local law. No question on this application is intended to secure information to be used in a discriminatory manner.

Office Use Only: _____H _____F _____LTR

Full Name (Last, first, middle)
Date Application Completed
Current Address	Number and Street
	City State Zip Code
Telephone Number	Home Work
Social Security Number
Previous Address	Number and Street
	City State Zip Code

*Job Interest and Employee Referral*
Kind of Employment	Full time Part Time Temporary or Summer
Geographic Preference
When can you report to work?

Specific type of work desired:

How did you find out about this opportunity?

Job Skills	Typing (WPM) Data Entry (Key Strokes) Equipment
Salary Requirements

*Military Service*
Date of Discharge
Military Branch
Rank at Discharge
Duties

*Education*
Graduate or Post College School Name & Location
Dates Attended	From To
Avg. Grade /PT. Hr.
Did You Graduate?	Y N
Degree Received
Major Subjects Studied
College School Name & Location
Dates Attended	From To
Avg. Grade /PT. Hr.
Did You Graduate?	Y N
Degree Received
Major Subjects Studied
Secondary or High School School Name & Location
Avg. Grade /PT. Hr.
Did You Graduate?	Y N
Degree Received
Major Subjects Studied

*Work Experience - Current*
Company Name
	Starting Salary Leaving Salary
Date Employed	From To
Company Address	Street
	City State Zip Code
Supervisor's Name
Supervisor's Phone Number	Permission to Contact? Y N
Reason for Leaving
Last Position Held
Major Responsibilities

*Work Experience - Next Most Recent*
Company Name
	Starting Salary Leaving Salary
Date Employed	From To
Company Address	Street
	City State Zip Code
Supervisor's Name
Supervisor's Phone Number	Permission to Contact? Y N
Reason for Leaving
Last Position Held
Major Responsibilities

*Work Experience - Next Most Recent*
Company Name
	Starting Salary Leaving Salary
Date Employed	From To
Company Address	Street
	City State Zip Code
Supervisor's Name
Supervisor's Phone Number	Permission to Contact? Y N
Reason for Leaving
Last Position Held
Major Responsibilities

Professional Designations Include professional designations attained and designations in some form of completion.
Designation Name
	Date Received Date Part Last Taken
	Number of Parts Completed
If applicable, do you possess a current license and/or certification for the position for which you are applying? Y N Description:

Activities / Training Describe any professional activities in which you have participated. Do not include anything which might indicate race, religion, color, age, sex, disability, military or veteran's status, national origin, or any other basis protected by federal, state or local law. Describe any training programs you have participated in that may relate to your job skills.



References List two school or employment references the company has permission to contact (other than supervisors listed under work experience section).
First Reference	Name
	Business or Occupation Telephone Number
	Address
Second Reference	Name
	Business or Occupation Telephone Number
	Address

Personal Data

Have you been convicted of a felony or a misdemeanor? Please list all convictions. An arrest or conviction record will not automatically bar you from employment
Y N - If "yes", please explain:

If hired, can you submit proof of U.S. Citizenship or of lawful alien status, other than a student visa, which permits you to work in the U.S.? Y N

During the past five years, have you ever been denied a driver's license or convicted of a moving traffic offense, including, but not limited to, driving while intoxicated or reckless driving? An arrest or conviction record will not automatically bar you from employment. Answer this question ONLY if travel or driving is a necessary part of the job you are seeking. This does not mean driving to and from work.
Y N - If "yes", please explain:
State Driver's License #

Signature - PLEASE CAREFULLY READ THE FOLLOWING STATEMENT AND THEN SIGN THE APPLICATION IN THE SPACE PROVIDED.

I understand that as an applicant for employment I must undergo drug testing. I understand that if I refuse to take or fail the drug test, I am disqualified from further employment consideration. If employed by The Motorists Insurance Group, I furthermore agree to take a drug test whenever requested by the company. I understand that refusal to submit to a drug test during my employment will subject me to disciplinary action up to and including the termination of my employment

In consideration of my employment, I agree to conform to the rules and regulations of The Motorists Insurance Group. I understand my employment is for no definite period of time and regardless of the timing or manner of compensation, my employment may be terminated at any time, with or without cause, notice or both, at the option of the company or myself. I understand the president of The Motorists Insurance Group is the only company representative authorized to make any agreement contrary to the foregoing.

In completing this employment application, I grant permission to The Motorists Insurance Group to inquire about applicable background information. I also grant permission to all appropriate parties to release such information. Inquiry may include, but is not limited to: conviction record, motor vehicle record, credit check, references, and copies of prior personnel files. I understand any misleading, false or incorrect statement could be cause for immediate dismissal in the event of employment and with this knowledge I wish to continue with the application process.

By signing this employment application, I agree that any claim or lawsuit relating to my employment with The Motorists Mutual Insurance Company or any of its companies, subsidiaries or affiliates must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

Applicant's Signature: __________________________________ Date: _____________

Office Use Only - Do not write below this line

Employment Date

Classification Title

Rate Group

Division

Department

Salary

Source

Reports to:

Employee No

Comments:

__ PT/Temporary

__ PT/Regular

__ FT Exempt

__ FT Non/Exempt

Location
__ Home Office
__ Branch
__ Field

Authorization

M-406 (3-09)

Mail to: The Motorists Insurance Group, Human Resources Division,
471 E. Broad St, Columbus, Ohio 43215

Drug Test Consent Form

As a matter of policy and to ensure a work environment free of abuse of controlled substances or use of illegal drugs, The Motorists Insurance Group uses drug testing as a condition of employment. All employment offers are contingent on the results of a drug screen. Applicants refusing to participate in pre-employment drug testing will not receive further consideration for employment at The Motorists Insurance Group.

Positive test results or results determined to be altered or unreadable (not followed by an adequate explanation) will eliminate the applicant from further consideration. This assumes the results are confirmed by an independent laboratory retest which, in the opinion of The Motorists Insurance Group's medical representative, follow the application of appropriate testing protocol. In such a case, the applicant may reapply for employment with The Motorists Insurance Group after one year.

In the event of positive test results or results determined to be altered or unreadable I hereby authorize my personal physician or any other person or institution that has any records or knowledge of me, to give this information to the medical representative for The Motorists Insurance Group.

This authorization, or a photographic copy, shall be valid for a period not to exceed one year from the date signed.

I acknowledge that I have read and understand the above and that I agree with the conditions. I knowingly and voluntarily consent to the testing procedures. I release The Motorists Insurance Group, including any and all of its officers, agents, representatives and employees, and further release any physician, other person, or institution from any liability associated with or arising from the submission of my urine or blood for chemical analysis or for seeking or providing information about me.

AGREED TO:

____________________	________________________________________
Date	Signature
____________________	________________________________________
Date	Witnessed By

REFUSED:

____________________	________________________________________
Date	Signature
____________________	________________________________________
Date	Witnessed By

DISCLOSURE: OBTAINING AN INVESTIGATIVE CONSUMER REPORT
PURSUANT TO 15 U.S.C. 1681(d)(a)

As part of its employment process, The Motorists Insurance Group may obtain an investigative consumer report for employment purposes. This may include information as to your character, general reputation, personal characteristics and mode of living. Inquiry may include, but is not limited to: conviction records, motor vehicle records, credit checks, references and copies of prior personnel files.

You have the right to request additional disclosures under federal law. Upon your written request, made within a reasonable time, The Motorists Insurance Group will disclose the nature and scope of the investigation requested. The Motorists Insurance Group will send this information within five days of receiving your written notice.

This disclosure is made pursuant to the Fair Credit Reporting Act, 15 U.S.C. 1681(d).

AUTHORIZATION TO OBTAIN CONSUMER REPORT
PURSUANT TO 15 U.S.C. 1681(b)(a)(b)(2)

I authorize The Motorists Insurance Group to obtain a consumer report for employment purposes. I understand that inquiry may include, but is not limited to: conviction records, motor vehicle records, credit checks, references and copies of prior personnel files.

This authorization will remain in force until you specifically revoke it in writing. Accordingly, by signing below, you are authorizing The Motorists Insurance Group to obtain an investigative consumer report at any time during your employment or during any litigation resulting from your employment. A photocopy of this authorization shall be as effective as the original.

______________________________	______________________________
Name of Authorizing Consumer (Please Print)	Signature of Authorized Consumer

This authorization is given pursuant to the Fair Credit Reporting Act, 15 U.S.C. 1681b(b)(2).