New Hire Information

New Hire Information Form

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Please fill out all information listed below:

Full Name*:

Preferred Name for business cards and Lead system*:

Address*:

City*:

State*:

Zip Code*:

Address you want on your Business Card*:

Social Security Number*:

Date of Birth*:

Email Address*:

Home Phone*:

Cell Phone*:

Emergency Contact Name*:

Emergency Contact Phone*:

Do you have an active Life and Health insurance license?*:

Yes No

State(s) where licensed*:

Do you have Errors and Ommissions insurance?*:

Yes No

Have you ever filed for bankrupcy?*:

Yes No

Do you have a vector hit or do you owe any insurance companies money?*:

Yes No

If yes to any questions listed above, list details:

List any Insurance Carriers you sell or have sold for, and status:

How did you hear about us?*:

If referred, name of referring agent:

Expected Start Date*:

Date expected to attend Sales School*:

Name of Regional Sales Manager*:

Please list any Food Allergies you have*:

Spouse's Name*:

Spouse's Birthday*:

Wedding Anniversary*:

Names and Ages of Children*:

I authorize Cornerstone Senior Services, LLC, to do a background check and credit history check*:

Yes No

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