Prospect Notification Form

Step 1 of 5

Prior to beginning this form, please note that one of the questions asks if you have completed an OSHA Establishment Search. If you are unfamiliar with this process, please click the following link for a tutorial:
Click Here for the OSHA Establishment Search Tutorial
Staffing Company Name*
Contact Name*
First Last
Email Address*
Phone*
Hidden
Today's Date*
MM slash DD slash YYYY

Does this prospect notification in any way involve the production or sale of cannabis-based products?*
- Yes
- No
InSource can offer coverage for cannabis production and sales in the following states: AL, AR, AZ, CO, CT, DC, DE, FL, GA, HI, IA, IL, IN, KY, LA, MD, MN, MO, MS, MT, NC, NE, NM, NV, OK, SC, SD, TN, TX, UT, VA, VT, and WV.

Before continuing with this prospect notification form, click here to download our Cannabis Supplemental Form. After completing this PDF, please save it to your computer and upload it using the file upload section below.
Cannabis Supplemental Form Upload*
Accepted file types: pdf, Max. file size: 5 MB.

Prospect Data
Prospect Company Name*
Prospect FEIN Number
Website
Prospect's Mailing Address*
Street Address Address Line 2 City Prospect State ZIP Code
Prospect's Phone Number
Will your employees perform their work at a different address than the Prospect Mailing Address above?*
- Yes
- No
Employee's Work Address*
Please provide the address where your employees will perform work.

Street Address Address Line 2 City Work State ZIP Code
If approved, which address should be used in the Certificate Holder box on the Certificate of Insurance?*
Proposed Effective Date*
MM slash DD slash YYYY
Does this prospect require any endorsements such as a Waiver of Subrogation or an Alternate Employer Endorsement?*
- Yes
- No
Please provide the endorsement requirements below or upload sample documents using the file upload area below.*
Upload sample certificates and/or endorsements.
PDF Documents Only
Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 5.
Detailed Description of Prospective Client's Business (not job specific duties)*
In order to prevent a delay, please be detailed in your response.
Temporary Staffing Employee Information
State + Class Code
Number of Temporary Employees*
Detailed Description of Job Duties*
Estimated Annual Payroll*
Please enter a number greater than or equal to 100.
State + Class Code
Number of Temporary Employees
Detailed Description of Job Duties
Estimated Annual Payroll
Please enter a number greater than or equal to 100.
State + Class Code
Number of Temporary Employees
Detailed Description of Job Duties
Estimated Annual Payroll
Please enter a number greater than or equal to 100.
State + Class Code
Number of Temporary Employees
Detailed Description of Job Duties
Estimated Annual Payroll
Please enter a number greater than or equal to 100.

Upload any supplemental documents.
PDF Documents Only. Examples may include job descriptions or other supporting documents.
Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 5.
Please Type Your Name*
First Last
Consent*
By submitting this form I agree to the below:
By submitting this form, you agree that you are signing this form electronically and that all information you provided to InSource Employer Solutions and Business Insurers of Georgia is complete and accurate to the best of your knowledge. You agree your electronic signature (hereafter referred to as "E-Signature") is the legal equivalent of your manual signature. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature.

Click Here to download a fillable Prospect Notification Worksheet (PDF).
To officially submit a prospect, complete the online form.

Prospect Notification Form

Step 1 of 5

Prospect Data

Temporary Staffing Employee Information

Client Information

Client Risk Management Programs