Business Client Intake Form



General Information:

1. Name of business

2. Headquarters address

3. Person and address to which billings should be sent?

4. Date of incorporation

5. State of incorporation

6. States are you licensed to do business in

7. Fictitious business names used

8. Corporate affiliates (parent and or subsidiary companies)

Insurance information:

9. Name and title of Risk Management officer

10. Name of insurance broker

11. Insurance carriers, policy numbers, and dates. (Auto, CGL, Employer, Workers' Comp.)

 

Legal Information:

12. General counsel's name

Business address

Telephone number

Fax number

 

13. Name and Title of Officer in charge of litigation

Business address

Telephone number

Fax number

 

14. Name any other (outside) counsel you have consulted about this case?

 

15. What if any, papers have you been served with concerning this case?

 

16. Please describe any internal investigation you conducted concerning this case.

 

17. Please describe any statements that have been made to anyone outside the company concerning this case.