Prospect Notification Form

Prospect Data

Prospect Company Name*

Prospect FEIN Number

Website

Prospect's Mailing Address*

Street Address Address Line 2 City Prospect State ZIP Code

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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

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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*

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.

Prospect Notification Form

Step 1 of 4

Prospect Data

Temporary Staffing Employee Information

Client Information

Client Risk Management Programs