Prospective Client Survey Client Prospect Survey Use this form to provide preliminary risk-related information to InSource. Step 1 of 4 25% Submitter's InformationPlease provide information on the individual completing this form by providing name, title, email address, and phone number.Submitter's Name(Required) First Last Submitter's Title(Required)Submitter's Email(Required) Submitter's Phone Number(Required) General InformationDescription of Operations(Required)Business Entity Name(s)Please include any entity with separate FEIN numbers that will run payroll and require workers compensation coverage. Use the + button at the end of the row to add additional entity names. If there are any associated DBAs that need to be included on the certificate of insurance, please include it in the DBA column by each entity listed.Legal Entity NameFEIN #DBA (if used) Add RemoveAre there any other names or subsidiaries that do not run payroll, such as a holding company, that we need to be aware of?(Required) Yes No Please provide the name(s) of the additional business names or subsidiaries below.(Required)LocationsMain Office Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a separate mailing address from the address listed above?(Required) Yes No Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional LocationsPlease list any additional location addresses here, if applicable.Street AddressStreet Address 2CityStateZip Add Remove Service Agreement ContactEnter the name, title, email, and phone number of the person authorized to receive and sign the service agreement.Service Agreement Contact(Required) First Last Service Agreement Contact Title(Required)Service Agreement Contact Email(Required) Service Agreement Contact Phone(Required)Billing ContactEnter the name, title, email, and phone number of the person who serves as your primary billing contact – i.e. the person who handles reporting payroll to us for workers compensation premium calculation.Billing Contact Name(Required) First Last Billing Contact Title(Required)Billing Contact Email(Required) Billing Contact Phone(Required)Payroll Provider Software(Required)Please select.Accounting CS - Thomson ReutersAccounting WorldAdaptSuite by BullhornADPAdvanceAdvanced PartnersАрехAsureAutomotive Business DesignAvionteBaron PayrollBridgeware-Temps PlusCarvinCOATSCorporate Payroll ServicesCriterionElmpactEvolutionExact PayrollExodus HRGI Accounting Services Inc.GustoHeartland PayrollInternal Payroll - No ProvideriSolvedMadisonMicrosoft Dynamics GPNetworkers FundingPatriot SoftwarePaychexPaycomPaycorPaylocityPayNorthwestPayrollcentsPMI ResourcesPrismHRPropelHRQuickbooksRipplingSageSDP (Southland Data Processing)Signum HRSurepayTemp PlusTempWorksUKGUltra EdgeVensureWürkZenefitsZoho BooksOther / Not ListedName of Other Payroll Provider Software(Required)Claims ContactEnter the name, title, email, and phone number of the person who serves as your primary reporter for workers compensation claims.Claims Contact Name(Required) First Last Claims Contact Title(Required)Claims Contact Email(Required) Claims Contact Phone(Required) Employee / NCCI Class Codes / PayrollDo you have any subcontractors?(Required) Yes No Do your subcontractors provide their own workers compensation coverage or will they be covered under this program?(Required) Subcontractors will provide their own workers compensation coverage. Subcontractors need to be covered under this program. Is there any driving exposures while on the job?(Required)If yes, please explain in more detail. Yes No Driving Exposure Details(Required)Is there any height exposures over 6'-8"?(Required)If yes, please explain in more detail. Yes No Height Exposure Details(Required)Are any group transportation, ride sharing, provide transportation or payroll deduction for travel to and from work?(Required)Ground transportation is defined as more than four employees in a vehicle at one time. Yes No Do you use vans and/or busses? Are employees’ reimbursed in any way for travel to/from work?(Required)Is there out-of-state travel for work?(Required)If yes, please explain in more detail. Yes No Out-of-State Travel Details(Required)
