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:__________________   

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:_____________________________________________________