Independent Contractor Information Form

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Full Legal Name Date Business Name (DBA) Mailing Address City State Zip Phone Number Email Address Date of Birth SSN / EIN Driver's License # State Issued

Primary Services Provided

Police Security Police Escort Personal Protection Other

Other Service Detail

Type of Business Entity Other Business Entity Federal Tax ID (EIN) State of Formation State Tax ID (if applicable) Workers' Compensation Insurance Carrier Workers Comp Policy Number Workers Comp Expiration Date General Liability Insurance Carrier General Liability Policy Number General Liability Expiration Date

Professional Liability Insurance?

Yes No

Insurance Carrier Professional Policy Number Professional Expiration Date

Emergency Contact Name Relationship Emergency Contact Phone Alternate Phone

Bank Name Account Holder Name Routing Number Account Number

Account Type

Checking Savings

Officer Initials Acknowledgement Date

Contractor Signature

Printed Name Signature Date

LE360 Representative Name

Representative Printed Name Representative Date