Business Information Form

New Client Information Form
Tell Us About Your Business....
Business Name*
Business Entity Type*
Federal EIN #*
DBA (If Applicable)
Year Started*
DOT # (If Applicable)
Owner's Name*
Owner's Email*
Phone Number
Business Physical Address*
Is the Business Mailing Address the same as the Physical Address?*

YesNo
Mailing Address
Key Company Personnel:
Person responsible for the business insurance.
Business Insurance Person*
Email*
Phone Number*
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Add Key Personnel
Full Name
Email
Phone Number
Title
Brief Description of Operations:
Tells us what your business does.*
Business Insurance Quoting Information:
Worker's Compensation Quote?*

YesNo
Worker's Compensation Insurance
Payroll, Employees & Sub-contractors (1099's):
Payroll:
Total Company Payroll*
Total # of Employees*
Total Payroll Costs Including 1099
Company Payroll by State and Class Code:
Subcontractor Compensation:
Does your company use Sub Contractors (1099's)?*

YesNo
Do the subcontractors have their own insurance?

YesNo
Total Sub-Contractor Payroll (1099)
Owners and Officers Inclusion / Exclusion:
Work Comp allows Owners and Officers to be excluded by choice.*
Work Comp Coverage Questions:
Have you, in the past, present, or discontinued operations involved storing, treating, discharging, applying, disposing, or transporting hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)*

YesNo
Is work performed underground or above 15 feet?*

YesNo
Is the applicant engaged in any other type of business?*

YesNo
Is a written safety program in operation?*

YesNo
Is there any group transportation provided?*

YesNo
Any employees under 16 or over 60 years of age?*

YesNo
Any seasonal employees?*

YesNo
Is there any volunteer or donated labor? *

YesNo
Any employees with physical handicaps?*

YesNo
Do any employees travel out of state?*

YesNo
Are physicals required after offers of employment are made?*

YesNo
Any prior coverage declined / cancelled / non-renewed in the last three (3) years? *

YesNo
Do any employees perform work for other businesses or subsidiaries?*

YesNo
Do you lease employees to or from other employers?*

YesNo
Do any employees predominantly work at home?*

YesNo
Any tax liens or bankruptcy within the last five (5) years? *

YesNo
Any undisputed and unpaid workers' compensation premium due from you or any commonly managed or owned enterprises? *

YesNo
General Liability Quote?*

YesNo
General Liability Insurance
General Liability insurance is rated on payroll and or revenue. Please provide the total annual revenue for the company.*
Do you utilize Subcontractors?*

YesNo
Do Subcontractors provide Certificates of Insurance?*

YesNo
Do you Required to have your company named as Additional insured on the subcontractors policies?*

YesNo
Do you obtain a Waiver of Subrogation?*

YesNo
Do you Obtain a Hold Harmless Agreement?*

YesNo
Do you verify that all hired subcontractors carry workers compensation insurance?*

YesNo
Business Auto Quote?*

YesNo
Business Auto Insurance
Are MVR's checked on new drivers prior to hire?*

YesNo
Is there a written driver training program?*

YesNo
Is there a written distracted driver policy, including cell phones and other mobile devices?*

YesNo
How often are MVR's checked on existing drivers?*
How many drivers are younger than 25 years of age?*
How many drivers are older than 65 years of age?*
Minimum Years of driving experience required?*
How many new drivers were hired in last 12 months?*
What is the number of allowable violations / citations in the prior 3 years?*
What is the allowable number of accidents in the prior 3 years*
ADD VEHICLES:
Vehicle List:
ADD DRIVERS:
Driver List:
Please upload the following Documents:
- Driver's list (excel format preferred) - Full name, Date of Birth, License number, State of Issue.
- Vehicle list (excel format preferred) - Year, Make, Model, Vin #, cost new or value of the vehicle, garage location (if different from physical business location).
- Copy of current business auto policy.
Secure File Upload:

Cancelof
Best Safety & Risk Management Assessment?*

YesNo
Risk Management & Safety: Best Practices Assessment
Does your company have a dedicated Safety Director ?*

YesNo
Does your company have a written Safety policy?*

YesNo
Are employees allowed to take company vehicles home at night and/or utilize them for personal use?*

YesNo
Do you have an accident investigation process?*

YesNo
Do you maintain an accident register?*

YesNo
Does your company utilize telematic software for your fleet?*

YesNo
Does your company have a dedicated HR Director employed?*

YesNo
How often are Safety Meetings held?
Secure File Upload
Please upload the following Documents:
- Current Certificate of Insurance including any endorsements needed for contractual purposes.
- Driver's list (excel format preferred) - Full name, Date of Birth, License number, State of Issue.
- Vehicle list (excel format preferred) - Year, Make, Model, Vin #, cost new or value of the vehicle, garage location (if different from physical business location).
- Copies of current policies (all lines).
Accepted file types: .jpg, .pdf, .png, .xls, xlsx

Max file size: 1 GB.
Cancelof
Please verify that you are human*
What date do you need this by?

MonthDayYear
T. Hudson Risk Advisor
T. Hudson Risk Advisor EMAIL
Should be Empty:

New Client Information Form

Business Insurance Quoting Information:

Worker's Compensation Insurance

General Liability Insurance

Business Auto Insurance

Risk Management & Safety: Best Practices Assessment

Secure File Upload