NC Sample Audit-WC-GLm
7 Pages
English
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NC Sample Audit-WC-GLm

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Learn all about the services we offer
7 Pages
English

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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:
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
x
x
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
x
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
Pa
e 1 of 2
8
 3,633
 3,633
 35,203
 35,203
 28,200
 84,288
 344,01
8
 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
 5
 5
 578,544  74,400  124,138  0  0  0  628,282
8
3
 21,6
VA
3
1,6
 2
 7,075
8
 7,075
8
2,27
5403
5445
HVAC
VA
Clerical
VA
VA VA
VA
 28,200
VA
 344,018
 84,288
VA
VA
Carpentry NOC
Drywall
 0
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
VA
Plumbing
VA
ess officer excess
l
Uninsured subs
per worksheet
 3
6
,3
7
6
 0
 0

A S S O C I A T E S
 0
I N C O R P O R A T E D
 1
 0
 2
0,268
,1
6
8
0
5183
8742
e 2 of
Pa
To Audit Summary
2
 26,000
 0
 0
 0
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
, 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 ~
C
E
~ R
~~~
~
 0
 0 0
 0
 0
 0
 0
 0
 0
~~~
~
0
7
6
1
2 07  3,552  1,251  3,208  1,530  727
 8,000  5,488  5,490  4,185  2,945
07
3
4
0
contracto contracto contracto Contracto Contracto Contracto Contracto
STANDARD EXCEPTION AND KEY P
RM
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
S
  
  
  
  
                      
0
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
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
s
 74,400
                                  
                                                                    
                                  
d ust to Minimum                                                                                                                                                                                                                                                                     
O
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
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