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NC Sample Audit-WC-GLm

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RLDA S S O C I A T E SI N C O R P O R A T E DUNDERWRITING ALERT FORMABC Insurance CompanyWorker`s Compensation AuditControl No.: 123456Ref. #: Insured: ABC Insured Address: Policy No.: 12-WC-234567-89101-2-AC-34567-8910- Somewhere, VA 24382 Audit Date: 06-Feb-08Policy Period: 10/10/2006 to 10/10/2007 Federal ID #: Audit Period: 10/10/2006 to 10/10/2007 Contact: Audit ContactType of Org: Corporation Title: Auditor: John Doe CLASSIFICATION CHANGES:Code No. Code Wording Code No. Code WordingAdd Code: 5437/91341 Floor sanding Delete Code:5445/92338 Drywall8742 outside salesCHANGE IN ENTITY TO:CORPORATION EFFECTIVE DATE OF CHANGE:PARTNERSHIPSOLE PROPRIETORSHIPADDRESS CHANGE: EFFECTIVE DATE OF CHANGE:New Address: ACTUAL EXPOSURES AS COMPARED TO ESTIMATED EXPOSURES VARY BY MORE THAN 20% (EXPLAIN BELOW).UNINSURED OR UNDER INSURED SUBCONTRACTOR EXPOSURE FOUND AT TIME OF AUDIT. PLEASE REFER TO THEATTACHED SUBCONTRACTOR SCHEDULE.COMMENTS:Per audit contact, Sec/Treas:5022, and 5474 above estimate due to more of those type of work during policy period.91583 lower than estimate due to less work. 97447 and 98305 higher due to more of that type of work during policy period. RLDA S S O C I A T E SI N CO R P O R A T E DABC Insurance CompanyWorker`s Compensation AuditControl No.: 123456Insured: ABC Insured Address: 0 Ref. #: Policy No.: Somewhere, VA 24382 Phone No. 555-555-555512-WC-234567-8910- 12-AC-34567-8910-Policy Period: 10/10 ...

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BC Insurance Company W orker`s Compensation Audit

 A S S O C I A T E S I N C O R P O R A T E D

UNDERWRITING ALERT FORM

Insured:ABC InsuredAddress: Policy No.: 12-W C-234567-891 12-AC-34567-8910-Policy Period: 10/10/2006 to 10/10/2007 Audit Period: 10/10/2006 to 10/10/2007 Contact: T pe of Or : Corporation Title:

CLASSIFICATION CHANGES: Code No. Code W ording Add Code:5437/91341 Floor sanding 5445/92338 Drywall 8742 outside sales

CHANGE IN ENTITY TO: CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP

ADDRESS CHANGE: New Address:

Somewhere, VA 24382 Audit Contact

Delete Code:

EFFECTIVE DATE OF CHANGE:

uditor:

Code No.

Control No.: Ref. #: Audit Date: Federal ID #:

John Doe

Code W ording

ACTUAL EXPOSURES AS COMPARED TO ESTIMATED EXPOSURES VARY BY MORE THAN 20% (EXPLAIN BELOW ).

123456 06-Feb-08

UNINSURED OR UNDER INSURED SUBCONTRACTOR EXPOSURE FOUND AT TIME OF AUDIT. PLEASE REFER TO THE ATTACHED SUBCONTRACTOR SCHEDULE.

COMMENTS:

Per audit contact, Sec/Treas:

5022, and 5474 above estimate due to more of those type of work during policy period.

91583 lower than estimate due to less work. 97447 and 98305 higher due to more of that type of work during policy period.

505.50% 49.62% -51.38% -11.79% 19.92%

Control No.: 123456 Ref. #: Phone No.55555-555-55 Federal ID #: Auditor: CorporationType of Org. John Doeudit Date:0b-086-Fe Description of Operations Insured is a corporation located in Somewhere, VA and is engaged in building commercial buildings less than 3 stories and residential houses 1-2 stories, remodeling, including, roofing incidental to the construction,, decking, doors, windows, new additions and HVAC contracting and is correctly classified as 1234-Carpentry for WC and 12345 Carpentry for GL.. Exit interview with audit contact, Secretary/Treasurer. Ok to release audit to agent.

BC Insuredddress: 0 12-WC-234567-8910- 12-AC-34567-8910- Somewhere, VA 24382 10/10/2006 to 10/10/2007 0 10/10/2006 to 10/10/2007 Contact: udit Contact Title: 0 ~~~~~ AUDIT SUMMARY ~~~~~ # of Policy Code Classification Exposure Emp Estimate 5221 Concrete 52,278 5437 Flooring 7,075 5190 Electrical wiring 21,638 1 5022 Masonry NOC 3,633 600 5474 Painting/Papering 35,203 23,528 8810 Clerical 28,200 2 58,000 5536 HVAC 84,288 7 95,550 5403 Carpentry NOC 344,018 21 286,861 5445 Drywall 25,949 5183 Plumbing 8742 Outside sales 26,000 1 628,282 MAX emplo ees per loc Total er Reca 628,282

No exposure under 5183.

Condition of Recs: Cooperation: Subcontractors:

Good Good Yes

UC2's941's 144,697 128,825 141,520 161,502 576,544 49,738

Commissions Company carSource of Data: Min/Max earnings (74,400) Payroll Records Lodging/meals Cash Disburse. Deferred wages General Ledger Life Insurance Check Book Premium overtime General Journal Uninsured subs 124,138 Income Statem't 49,738Other

Tips 401k/IRA Bonus

4q06 1q07 2q07 3q07 subtotal total adjustm'ts

Adjustments:

Verification: per audit

628,282

626,282

erified Total

BC Insurance Company Worker`s Compensation Audit

Insured: Policy No.: Policy Period: udit Period: Rating Date:

First W /E Date L

Continuit # of W eeks

 A S S O C I A T E S I N CO R P O R A T E D

ast W /E Date udit Notes: Audit period 10/1/6-10/1/7. Payroll was taken from this period and verified with the state and federal reports filed and the short periods adjusted.

No evidence of overtime.

State V V V V V V V V V V V

Gross Revenue - $2,391,422

per worksheet #1

less officer excess

25,949

Address:

Ref. #:

Control No.:

Federal ID #

Audit Date:

Type of Org.

123456

06-Feb-08

Corporation

e 1 of 2

3,633

35,203

28,200

84,288

344,01

25,949

Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee Employee

Employee

Auditor:

John Doe

To Audit Summary

Uninsured subs

2,27

578,544 74,400 124,138 0 0 0 628,282

21,6

1,6

7,075

2,27

5403

5445

HVAC

Clerical

VA VA

28,200

344,018

84,288

Carpentry NOC

Drywall

Total

5221 Concrete

Duties su ervisor of HVAC Instalation checks jobsite progress, estimates, office paperwor k & admin Bookee in , office a erwork, A/P, A/R Pa roll Car entr , interior, finish Car entr , framin Car entr , framin Car entr , framin Car entr , framin elrctrician Car entr , framin , finish HVAC Installation Car entr , framin , finish Car entr , framin , finish Car entr , framin , finish HVAC Instalation Car entr , framin , finish Car entr , framin Car entr , framin , finish Car entr , framin , finish Car entr , framin , finish Car entr , framin , finish Car entr , framin , finish HVAC Instalation Car entr , framin , finish 0 0 0

4,090 4,985 3,968 6,978 5,525 2,368 4,880 7,680 131,252

11,982

5536

8810

Masonry NOC ainting/Paperin

Electrical wiring

Flooring

5437

~~~~~ RECAP ~~~~~ 5022 5474

5190

A 2

4382

12-AC-34567-8910-

BC Insured 12-WC-234567-8910-10/10/2006 to 10/10/2007 10/10/2006 to 10/10/2007



A S S O C I A T E S

I N C O R P O R A T E D

Somewhere, V

2 07 8,039 15,600 11,500 1,800 9,359 2,388 2,816 5,047 6,098 6,377 3,627 6,145

3 07 8,739 33,600 5,000 2,400 9,359 3,281 1,470 5,325 360 6,538 6,374 12,072 5,302 4,884 4,436 7,564 5,634 5,440 7,616 135,394

Total 31,656 100,400 20,000 8,200 37,436 13,270 6,020 12,073 19,613 21,638 25,417 15,446 22,999 7,545 49,209 6,430 10,446 18,054 18,055 17,196 26,309 17,609 7,336 12,080 15,731 540,168

Class VA5536 VA8742 VA8810 VA8810 VA5403 VA5403 VA5403 VA5403 VA5403 VA5190 VA5403 VA5536 VA5403 VA5403 VA5403 VA5536 VA5403 VA5403 VA5403 VA5403 VA5403 VA5403 VA5403 VA5536 VA5403 0

BC Insurance Com an Worker`s Com ensation Audi

Insured: Policy No(s).: Policy Period: Audit Period:

4 06 1 07 7,439 7,439 35,600 15,600 1,500 2,000 2,200 1,800 9,359 9,359 3,063 4,538 3,760 790 4,103 5,154 4,634 4,607 7,440 7,740 6,916 5,586 5,709 6,110 4,993 5,487 4,023 3,522 12,675 12,480 3,990 2,440 5,398 5,048 4,758 3,904 4,294 3,892 4,869 3,923 6,250 5,517 700 5,750 1,024 3,944 1,760 435 144,697 128,825

Outside sales

100,400 74,400

Plumbing

ess officer excess

Uninsured subs

per worksheet



A S S O C I A T E S

I N C O R P O R A T E D

0,268

5183

8742

e 2 of

To Audit Summary

26,000

V V V V V V V

Total 3,552 1,251 11,208 7,018 6,217 4,185 2,945

, finish , finish

Class A5403 A5536 A5536 A5403 A5536 A5403 A5403

, finish

Duties ar entr , framin VAC Instalation VAC Instalation ar entr , framin VAC Instalation ar entr , framin ar entr , framin

C H H C H C C

AP ~

~ R

~~~

0 0

~~~

2 07 3,552 1,251 3,208 1,530 727

8,000 5,488 5,490 4,185 2,945

contracto contracto contracto Contracto Contracto Contracto Contracto

STANDARD EXCEPTION AND KEY P

ERSONNEL FO

Audit Period: 10/10/2006 to 10/10/2007

Title:

Auditor: John Doe

8810 Bookeeping, office paperwork

e admin

Code Exact Duties 8742 goes to job sites to inspect for bidding purposes, estimates, offic

Contact:

A 24382

Somewhere, V

ABC Insured

Insured:

12-AC-34567-8910-

Policy No.: 12-W C-234567-8910-

Policy Period: 10/10/2006 to 10/10/2007



I N C O R P O R A T E D

A S S O C I A T E S

urer

Name President

ecretary/Treas

Audit Date:

Federal ID #:

Type of Org.

Audit Contact

BC Insurance Com an Worker`s Com ensation Audit

Address:

Wa es 100,400

06-Feb-08

18,000

Corporation

123456

President Secretar /Treas

urer

74,400

d ust to Minimum

wnership Summary

Name

Code 8742 8810

mount Included 26,000 18,000

44,000

o.:

Control N

Ref. #:

26,000

Maximum

Minimum 7,800 7,800

26,000

president

18,000

Excess 74,400

100,400

Title

ecretar /treas

Gross Wages

118,400

 A S S O C I A T E S I N C O R P O R A T E D

21,025 3,633 7,075 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 124,138

52,278 14,178

TOTAL WITHOUT CERTIFICATES

Audit Date:

Control No.: Auditor: Federal ID #:

TOTAL COST

209,168

123456 John Doe

85,030

TOTAL WITH CERTIFICATES

Page 1 of 1

Drywall Plumbing Electrical wiring Electrical wiring Drywall

5/10/7-5/10/8 8/4/5-8/4/6 10/24/6-10/24/7

06-Feb-08 Uninsured Limits Sub Cost 500,000 24,807 1,000,000 100,000 1,000,000 1,142

Eff. Dates 3/15/7-3/15/8

y y y y y y y y y y y y y

n n n n n y n y y y y n y

y y y y y

Paving Interior painting Insulation Insulation Masonry, Block & Brick Painting Masonry, Block & Brick Floor finishing

n y n n y n y y

3,633 7,075

24,807 21,596 8,262 9,245 1,142 52,278 14,178 6,606 15,605 20,476 21,025

100,000 100,000 100,000

8/27/5-8/27/6 8/30/6-8/30/7 4/15/7-4/15/6

1.00003E+12 Q123456789 FCD123456789

456 Mutual Insurance n one Insurance Gro Jon Doe's insurance C 5474 5022 5437

ABC Insured 12-W C-234567-8910-10/10/2006 to 10/10/2007 10/10/2006 to 10/10/2007 Corporation

mount 3,240

SUBCONTRACTOR ANALYSIS

Insured: Policy No.: Policy Period:

E n

SP y

L y

M y

Address: Somewhere, VA 24382 Contact: Audit Contact Title:

Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor Subcontractor

T e of Work Guttering

12-AC-34567-8910-

Code Ins. Co. Polic No. Jon Doe's Insurance Gr Q123456789 5445

Someone Insurance Gr Q123456789 Jane Doe's Mutual Insuran 12W C34567-8910 123 Insurance Group Q123456789 5445 waiver 5221 5474

Audit Period: Type of Org:

BC Insurance Company Worker`s Compensation Audit