Small Business Client Information Form

Customer Name:

No. Of Class Codes:

Client FEIN #:

Primary Contact Name:

Primary Contact Email:

Secondary Contact Name:

Secondary Contact Email:

Primary Broker Name:

Primary Broker Email:

Secondary Broker Name:

Secondary Broker Email:

Payroll Frequency:

First Check Date:

The first submission will be due on the first check date following the policy effective date and every pay period thereafter. Please enter that date here.

If you wish to print the form, please complete it in full and email it back to customersupport@insuredsolutions.net or fax to (678) 262-3201.