Prospect Notification Form

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*
Today's Date*
MM
DD
YYYY

Prospect Data
Prospect Company Name*
Prospect FEIN Number
Website
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax
Safety Contact
First Last
Years in Business
Proposed Effective Date*
Date Format: MM slash DD slash YYYY

Prospect Data
Detailed Description of Prospective Client's Business (not job specific duties)*

Temporary Staffing Employee Information
NCCI Class Code
Number of Temporary Employees*
Detailed Description of Job Duties*
Estimated Annual Payroll*
Please enter a number greater than or equal to 100.
NCCI Class Code
Number of Temporary Employees
Detailed Description of Job Duties
Estimated Annual Payroll
Please enter a number greater than or equal to 100.
NCCI Class Code
Number of Temporary Employees
Detailed Description of Job Duties
Estimated Annual Payroll
Please enter a number greater than or equal to 100.
NCCI 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 Risk Management Programs
What training does the staffing company provide?*
What training does the staffing company's prospect customer 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*

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 / 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. You acknowledge your understanding that any person who knowingly submits false or fraudulent information is guilty of a crime and may be subject to fines and/or confinement in state prison.
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Prospect Data