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
Format: (000) 000-0000.
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*
Format: (000) 000-0000.
Title
Add Key Personnel
Full Name
Email
Phone Number
Format: (000) 000-0000.
Title
Add Key Personnel
Full Name
Email
Phone Number
Format: (000) 000-0000.
Title
Add Key Personnel
Full Name
Email
Phone Number
Format: (000) 000-0000.
Title
Add Key Personnel
Full Name
Email
Phone Number
Format: (000) 000-0000.
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:

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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.
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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