New Broker Data Sheet

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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
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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:_____________________________________________________