BUSINESS CLIENT INTAKE FORM
General Information:
1. 2. Name of Business: _____________________________________________ Main address:
3.
Name of 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.
DBA/Fictitious business names used: ______________________________
8.
Corporate affiliates (parent and or subsidiary companies): ______________
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_________________________________________________________________
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 matter:
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____________________________________________________________
____________________________________________________________ Business Address
____________________________________________________________ Telephone Number
____________________________________________________________ Fax Number 14. Name any other (outside) counsel you have consulted about this matter?
____________________________________________________________
15.
What if any, papers have you been served with concerning this matter?
____________________________________________________________
16.
Please describe any investigation you conducted concerning this matter.
____________________________________________________________
____________________________________________________________
17.
Please describe any statements that have been made to anyone outside the Company concerning this matter.
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____________________________________________________________
____________________________________________________________
Notes/Other:
Additional information that relates to this Matter:
Date: ___________________ of _______________________, 2008.
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