Champion Hr New Broker Data Sheet

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New Broker Data Sheet

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Champion Hr New Broker Data Sheet

  1. 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. 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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