BUSINESS CLIENT INTAKE FORM
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)
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.)
12. General counsel's name
13. Name and Title of Officer in charge of litigation
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.
These forms are provided AS IS. They may not be any good. Even if they are good in one jurisdiction, they may not work in another. And the facts of your situation may make these forms inappropriate for you. They are for informational purposes only, and you should consult an attorney before using them.