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1. Name of applicant or insured: ________________________________________________________________________________

2. Please indicate the percentage of the applicant’s receipts generated by each service, total must equal 100%:

SERVICE PERCENTAGE OF RECEIPTS

Permanent placement/executive search %

Temporary placement/employee leasing %

3. Is the applicant a private employer organization (PEO)? Yes No

4. Please provide estimated gross revenues from the past 12 months EXCLUDING temporary placement

payroll: $ _______________________________________ OR provide most recent financial statements.

5. Please indicate the percentage of professionals placed in the following over the past 12 months, total must equal 100%:

T YPE OF PROFESSIONAL PERCENTAGE PL ACED

Accountant/CPA %

Administrative/clerical %

Architect/engineer %

Computer/technology %

Construction/skilled labor %

Consultant %

Driver/transportation %

Financial services %

Healthcare professional %

Industrial %

Janitorial %

Lawyer %

Nanny/child care provider %

Other (please describe): _________________________ %

6. Does the applicant provide any supervision/oversight of the services of the placed employees? Yes No

7. Does the applicant provide background checks on candidates before placement? Yes No

8. Please describe applicant’s screening process to determine employee suitability, including controls/testing used where

specific skills are required: ___________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

S U P P L E M E N TA L A P P L I C AT I O N

Employment agency or executive recruiter

119-10050 (6/19)

hanover.com

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653

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SIGNATURE IN FULL: _______________________________________________ DATE: ___________________________________

PRINT NAME: _____________________________________________________

ALL QUESTIONS MUST BE ANSWERED AND THE APPLICATION MUST BE SIGNED AND DATED

Agency Name and Address: ______________________________________________________________________________________

Person Submitting Application: ___________________________________________________________________________________

Telephone Number: _____________________________ Email: _______________________________________________________