Filling out and submitting this form does not constitute an offer of employment and we adhere strictly to the IRS definitions of an independent contractor.
Click here to view those criteria.

By filling out and submitting this form, the person/company whose name appears in the form represents that the information they are providing is accurate and truthful and submitted at their discretion.   The person/company submitting this form grants LMC Group permission to review and verify this information for consideration of using the named person's/company's services as an independent contractor. 

If LMC Group opts to use those services, additional information may be required and a contract must be completed and signed.

GENERAL INFORMATION
Name:
          
Address:
Street
   
City / State / Zip
    /    /  
Phones:
Home:     Business:     Mobile:    Fax:
E-mail:
   
PERSONAL PROFILE
Education:
College
 Degree
 Yr.
Graduate
 Degree
 Yr.
Other Training or schooling:
Industry Certifications: (Select all applicable)
ALCM CPCU B&M Ticket
ARM CSP CHCM
ASP IHIT CIH
EIT PE Other
Languages you speak (select any that apply):
English  Spanish  French  German   Other  
YOUR BUSINESS
Name under which you do business: 
How long have you been doing independent contract work?
Less then a year    1 - 3 years   4 - 10 years  More then 10 years
How many employees do you have? (Include yourself)
 1 - 3    4 - 10     More then 10 
Do you carry insurance? (check all that apply)
None  Business Owner's Policy  Liability Only  Auto    Workers Comp  E&O
Are you a:
Sole Proprietor  Partnership  Corporation  LLC or LLP    Other
How many companies do you currently subcontract to do work for?
1 - 3  4 - 10  More then 10 
BUSINESS / EXPERIENCE PROFILE
Work Experience: (Please list your present employer first)
1.

Dates:

From:  

To:  

Employer:

Location:

Position:

Your duties and responsibilities:
2.

Dates:

From:  

To:  

Employer:

Location:

Position:

Your duties and responsibilities:
3.

Dates:

From:  

To:  

Employer:

Location:

Position:

Your duties and responsibilities:
Check the industry types which you feel represent your greatest expertise:
Industrial Machinery or Consumer Products Manufacturing
Electronics Manufacturing
Food Manufacturing
Chemical Manufacturing
Hotel / Motel, Service Industries
Municipalities
Entertainment and Leisure
Construction
Please list any others below:
Technical Expertise: (Select all applicable)
Workers' Compensation Environmental
Products Liability Industrial Hygiene
General Liability Occupational Nurse
Fleet
Entertainment Insurance Non Loss Control areas
Construction Sales
Builder's Risk/Contractors Underwriting
Property Brokerage
Boiler & Machinery Agency
HPR Risk Management
Sprinklers/Hydraulic Calculations Plant Safety
Do you have any specialties? (Please list and describe)
    
What size accounts have you serviced (measured by premium size) ?
0-100K    up to 500K    up to 1M    Over 1M
What safety functions have you performed?
Develop Safety Programs    Inspections    Account Service    Prospecting
Have you coordinated national accounts?
Yes    No
Have you serviced multi-location risks?
Yes    No
Have you ever managed a staff of loss control or similarly professional people?
Yes    No
 1 - 5    6 - 10    More then 10
Are you willing to travel?
Will NOT Travel     1-10% of the time    10-25%     25-50%    50-75%
Within 100 miles only     200 miles     400 miles     More
Other Comments:
Based upon past business experience my strengths are:
     
I've come to know the following are some of my weaknesses:
     
How did you find us?