400 Robert Street North, St 2025

1. Click ‘Get Form’ to open the Broker Data Sheet in the editor.
2. Begin by filling out the 'Product Information' section. Indicate the line(s) of business you are requesting appointment for by checking the appropriate boxes for Life, Annuity, or Employer Plan (401K).
3. In the 'Broker Information' section, enter your full legal name as it appears on your insurance license. Include your date of birth, Social Security number, and email address for confidential information.
4. Complete your residential and business addresses accurately. Ensure that all fields including state, city, and zip code are filled out correctly.
5. If applicable, answer questions regarding Long Term Care products by selecting 'Yes' or 'No', and provide any necessary training certificates.
6. Fill in the Errors and Omissions Insurance Information with your carrier name, policy number, coverage amount, effective date, expiration date, and company contact.
7. Review the Broker Declaration section carefully. Answer each question truthfully and provide explanations if necessary.
8. Finally, sign and date the application in the designated area to certify that all information is accurate before submitting.

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