Prospect Notification Form | Business Insurers of Georgia

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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*

This field is hidden when viewing the form

Today's Date*

MM slash DD slash YYYY

Does this prospect notification in any way involve the production or sale of cannabis-based products?*

Yes

BIofGA can offer coverage for cannabis production and sales in all states except: NH, ID, KS, ME, NY, NJ, OR, PA, or RI.

Before continuing with this prospect notification form, click here to download our Cannabis Supplemental Form. After completing this PDF, please save it to your computer and upload it using the file upload section below.

Cannabis Supplemental Form Upload*

Accepted file types: pdf, Max. file size: 5 MB.

Prospect Data

Prospect Company Name*

Prospect FEIN Number

Website

Prospect's Mailing Address*

Street Address Address Line 2 City Prospect State ZIP Code

This field is hidden when viewing the form

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

Employee's Work Address*

Please provide the address where your employees will perform work.

Street Address Address Line 2 City Work State ZIP Code

This field is hidden when viewing the form

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*

MM slash DD slash YYYY

Does this prospect require any endorsements such as a Waiver of Subrogation or an Alternate Employer Endorsement?*

Yes

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.

Client Information

Has temp placement company visited the work site?*

Yes

Please provide details:

Did you complete an OSHA Establishment Search for this prospect?*

Yes

Explain the OSHA Establishment Search results (number of violations, types of violations, penalties incurred, etc...)*

We highly recommend you perform an OSHA Establishment Search for every new prospective client and consider the results when deciding if you want to do business with them. While performing a search is not currently required for you to submit this prospect for consideration, this may become a requirement in the future. If you have questions about how to perform an OSHA Establishment Search, please contact your BIofGA Account Manager.

Will there be any group travel or company transportation exposures?*

We define group transportation as more than two (2) employees in the same vehicle. This includes company-sponsored or subsidized transit.

Yes

How many employees will be in a vehicle at any given time?*

What type of vehicle is being used?*

Van

Crew Cab Truck

Truck

Car

Bus

Other

How many miles will be driven each way?*

Any trenching/excavation exposures?*

Yes

Please provide details:*

Is there any height exposure above ground level?*

Yes

What is the maximum height exposure?*

Is there any chemical exposure?*

Yes

Describe the type of chemicals and exposure to them*

Is there any machinery exposure?*

Yes

Describe type of machinery*

Do any operations require respirators or dust masks?*

Yes

Please provide details:*

Are there any airborne and/or bloodborne pathogens exposures?*

Yes

Please provide details:*

Client Risk Management Programs

What training does the staffing company provide?*

What training does the prospect company provide?*

Is PPE required for any of the job duties?*

Yes

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

Provide explanation*

Upload any supplemental documents.

PDF Documents Only. Examples may include job descriptions or other supporting documents.

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 5.

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 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.

Click Here to download a fillable Prospect Notification Worksheet (PDF).
To officially submit a prospect, complete the online form.