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2014 New Client
Information Worksheet
Insuring your business. Ensuring your future.
Business Contact Information
Insured’s Company Business Name:
Contact Name & Title:
Phone:
Cell:
E-mail:
Registered Address:
City:
State:
ZIP Code:
Number of Insureds to be considered for this captive:
(If more than one Insured to be considered, please list above and complete an additional Client Information Worksheet for each)
Business Information
Month, Day, Year & State Insured Business Commenced:
Sole Proprietorship:
Partnership:
Corporation:
LLC:
Number of Full-Time Employees:
Total Gross Revenue 2013:
Total Gross Payroll:
Projected Total Gross Revenue 2014:
Other:
Business Operations Information
Narrative of Business Operations:
Areas of Concern for Your Business:
Additional Information Required for Formal Analysis
1. Copies of Insured’s Current Market Policies; General Liability, Professional Liability, Employment-Related Practices, Directors &
Officers. (Not required, Worker’s Compensation, Automobile or Property.)
2. Last three years of audited financials (operating company)
3. Previous 2 years tax returns (operating company)
Signature:
Date:
Printed Name:
Title:
The information provided on this form is considered confidential and will not be shared with outside parties without prior permission.
Enterprise Risk Strategies | 4215 East McDowell Road, Suite 115, Mesa, Arizona 85215
ERS does not provide legal or tax advice
www.eriskstrategies.com
2014 New Client Information Worksheet
Disclosures
IRS Circular 230 disclosure: To ensure compliance with requirements imposed by the U.S. Internal Revenue Service, we inform you that any
U.S. federal tax advice contained in this PowerPoint is not intended or written to be used, and cannot be used, for the purpose of (a) avoiding
penalties under the U.S. Internal Revenue Code or (b) promoting, marketing or recommending to another party any transaction or matter
addressed herein.
The views and statements expressed in this presentation are for general information only. ERS, LLC is not, by means of this publication, rendering accounting,
business, financial, investment, legal, tax, or other professional advice or services. This presentation provides general information about certain legal and
accounting issues and should not be regarded as rendering legal or accounting advice to any person or entity. As such, the information is not privileged and
does not create a client relationship with the companies, or any of its employees. This presentation does not constitute an offer to represent you, and you
should not act, or refrain from acting, based upon any information so provided. In addition, the information contained in this presentation is not specific to
any particular case or situation and may not reflect the most current developments.
Insuring your business. Ensuring your future.
Robert Nizzi, President
11300 Tomahawk Creek Parkway
Leawood, KS 66211
tel: 913-220-0442
[email protected]
visit www.eriskstrategies.com
Enterprise Risk Strategies | 4215 East McDowell Road, Suite 115, Mesa, Arizona 85215
ERS does not provide legal or tax advice
www.eriskstrategies.com