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Prospect Notification Form

This online form is primarily used by InSource’s staffing clients to submit new prospects for underwriting approval. A fillable worksheet version in PDF is available at the bottom of this page. However, to officially submit a prospect, complete the online form.

Prospect Notification Form

Attention Business Insurers of Georgia clients! If your company is under our Business Insurers of Georgia program, please utilize your client portal account to submit a prospect notification for review.

Step 1 of 4

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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*
This field is hidden when viewing the form
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 all states except: NH, ID, KS, ME, NY, NJ, OR, PA, or RI.

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
Is this prospect submission for BID PURPOSES ONLY?*
- Yes
- No
Prospect Company Name*
Prospect FEIN Number
Website
Prospect's Mailing Address*
Street Address Address Line 2 City Prospect State ZIP Code
This field is hidden when viewing the form
Prospect Mailing State By Zip Validation
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
This field is hidden when viewing the form
Work Address Mailing State By Zip Validation
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.

Client Information
Has temp placement company visited the work site?*
- Yes
- No
Please provide details:
Did you complete an OSHA Establishment Search for this prospect?*
- Yes
- No
Explain the OSHA Establishment Search results (number of violations, types of violations, penalties incurred, etc...)*
We highly recommend you perform an OSHA Establishment Search for every new prospective client and consider the results when deciding if you want to do business with them. While performing a search is not currently required for you to submit this prospect for consideration, this may become a requirement in the future. If you have questions about how to perform an OSHA Establishment Search, please contact your InSource Account Manager.
Will there be any group travel or company transportation exposures?*
We define group transportation as more than two (2) employees in the same vehicle. This includes company-sponsored or subsidized transit.
- Yes
- No
How many employees will be in a vehicle at any given time?*
What type of vehicle is being used?*
- Van
- Crew Cab Truck
- Truck
- Car
- Bus
How many miles will be driven each way?*
Any trenching/excavation exposures?*
- Yes
- No
Please provide details:*
Is there any height exposure above ground level?*
- Yes
- No
What is the maximum height exposure?*
Is there any chemical exposure?*
- Yes
- No
Describe the type of chemicals and exposure to them*
Is there any machinery exposure?*
- Yes
- No
Describe type of machinery*
Do any operations require respirators or dust masks?*
- Yes
- No
Please provide details:*
Are there any airborne and/or bloodborne pathogens exposures?*
- Yes
- No
Please provide details:*
Client Risk Management Programs
What training does the staffing company provide?*
What training does the prospect company provide?*
Is PPE required for any of the job duties?*
- Yes
- No
What PPE is required for each job description?*
Who will furnish PPE and do appropriate PPE training?*
Will PPE be enforced for all workers, and is a written discipline policy in place?*
- Yes
- No
Provide explanation*

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.

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The information and forms presented on this website are intended for general reference only. We do not warrant, represent, or guarantee in any way the lawfulness of this information in your jurisdiction. Please consult your attorney before providing forms to prospective employees or current employees, and before amending your company policy. All liability for any actual or alleged loss, damage, or injury arising out of or resulting in any way from the use of this information is expressly disclaimed.

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