Audit Form

Business Information
Policy Number
Policy Holder Name
Report Period Start Date
Date Format: MM slash DD slash YYYY
Report Period End Date
Date Format: MM slash DD slash YYYY
Business Type
- Corporation
- LLC
- Partnership
- Sole Proprietorship
- Other
Federal Employer's ID Number (FEIN)
Is the information listed above correct?
- Yes
- No
Provide a detailed description of your business operations.

Audit Contact
Name
Title
Phone
Extension
Fax
Email

Ownership
Ownership
Name & Title Exact Job Duties Gross Wages*
Employees
Employees
Name & Title Exact Job Duties Gross Wages & Overtime* Overtime Wages

Employee Information. If necessary, attach pages or supply a payroll summary.
Upload Pages Or Payroll Summary
Drop files here or
*Gross wages represent the total paid to each person during the policy term before taxes, inducing commissions and bonuses.

Subcontractors
Did you use subcontractors during the policy term?
- Yes
- No
If yes, list below. Any individual or business that assists in providing a product or service to your customer but is not included in your tax returns as an employee (compensated by check or cash) would be considered a subcontractor. A subcontractor may work for another organization or may be independent.
Subcontractors
Name Or Business Name Job Duties Total Amount Paid
Attach your most recent filed 1009s (if any), the 1096, and valid certificates of Workers' Compensation (if any).
Drop files here or

Tax Documentation
Payroll Verification: Attach copies of the most recent four quarters of your IRS Form 941 (Employer's Quarterly Federal Tax Returns), or State Unemployment Tax Forms
Drop files here or
Statement
Any person who makes, or causes to be made, any knowingly false or fraudulent material statement or representation with the intent to defraud or deceive any insurance company regarding the proper calculation of premium, including (but not limited to) the amount of payroll or employee job duties or other facts relevant to the proper classification of payroll, commits a fraudulent insurance act, which is a crime and may subject such person to criminal or civil penalties.
I certify the information on this document to be complete and accurate.
Signature
Date
Date Format: MM slash DD slash YYYY
Premium Audit Checklist Reminder Be sure you have included: Audit Contact Information (Name & Phone Number) Subcontractor Forms (All 1099s, 1096, and certificates of Insurance For The Policy Period) Tax Documentation (IRS Form 941 or State Unemployment Quarterly Returns For The Mot Recently Completed Four Quarters.

Home Office Audit Department
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Audit Form

Business Information

Audit Contact

Ownership

Employees

Subcontractors

Tax Documentation

Statement

Name & Title	Exact Job Duties	Gross Wages & Overtime*	Overtime Wages