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Champion Hr New Broker Data Sheet
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Champion Hr New Broker Data Sheet

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New Broker Data Sheet

New Broker Data Sheet

Published in: Business, Economy & Finance
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  1.   BROKER PARTNER DATA SHEET Champion HR 9574 Topanga Canyon Blvd Chatsworth, CA 91311 PH 800.513.2153 FX 800.385.3185 URL www.Championhr.com       PERSONAL INFORMATION  Last Name  ____________________   First Name ___________________  Middle Name ___________  SSN:______‐______‐_________ Do you plan to market using a DBA?   Yes   No  If Yes, please provide  supporting documentation i.e. approval of required jurisdiction(s), DBA Name:_____________________  Date of Birth (Month/Day/Year):___________________________ Gender:   Male   Female  Residence/Home Address:_______________________________________________________________  City:____________________ State:_______ Zip:_________ Home Phone Number:_______________  Business  Address:______________________________________________ Suite: __________________  City:____________________ State:_______ Zip:_________ Business Phone Number:_______________  Cell Phone:_____________ Fax: _____________ URL: ______________    I am an officer of the below corporation  CORPORATE APPLICANTS (Individual Applicants Do Not Complete This Section)  Corporate Name:_________________________________________ EIN#_________________________  Do you plan to market using a DBA?   Yes   No  If Yes, please provide supporting documentation i.e.  approval of required jurisdiction(s), DBA Name:_____________________  Corporate Address:______________________________________________ Suite: __________________  City:____________________ State:_______ Zip:_________ Corporate Phone Number:_______________  State of Incorporation:_______________ Email: ____________________ Fax:____________________  Primary Officer for Corporate Records:____________________________________________________  Title of Primary Officer:__________________________________________________________________  LICENSING (Please provide copies of licenses and E&O Coverage)   P&C     Life Insurance   Group Health   Health   Long‐Term Care   Annuities   Securities  Resident State: ________ List Non‐Resident State: __________________________________________  E&O COVERAGE / BOND  Carrier: _______________________________ Policy #_________________ Expiration: _____________  Bond Holder:________________________________ Amount: __________________    AGENCY INFORMATION  Administrative Contact:________________________________ Email:___________________________  Sales Associates (Names):_______________________________________________________________  ____________________________________________________________________________________  Year Established: ___________________   # of Business Clients:__________________    
  2. INSURANCE PRACTICE & PREFERENCES  My practice will remain responsible for marketing, selling, and supporting the following:   Business Owners Insurance   Workers Compensation   Group Health Benefits   Voluntary Benefits  (Circle: Aflac, Colonia, Other:______________)   Group Pre‐Paid Legal   Life Insurance   Executive  Benefits/Insurance   401(k)   Other:______________________________________________________   Insurance and Financial Services not marketed, sold, and supported by me will be handled by:  Name of Agency:____________________________ Ph: ___________________ Email:_______________  Services they will provide are:____________________________________________________________    Champion HR may provide the following insurance and financial services to my clients:   Business Owners Insurance   Workers Compensation   Group Health Benefits   Voluntary Benefits  (Circle: Aflac, Colonia, Other:______________)   Group Pre‐Paid Legal   Life Insurance   Executive  Benefits/Insurance   401(k)   Other:________________________  LIST CARRIER APPOINTMENTS AND PRODUCTS YOU ARE APPOINTED TO MARKET  1.  2.  3.  4.  5.  6.  7.  8.  INTERNAL USE ONLY     Data Sheet   Commission Schedule   Licenses (copy)     W‐9 Form   E&O (Dec page copy)   POS Presentation     NDA   Bond (Dec page copy)   Partner Presentation    Verified by:_____________________________________________________ 

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