NC Sample Audit-WC-GLm

Description

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 ...

Subjects

• Documents
• Professional resources

Informations

• Published by: Nesog
• Reads: 32
• Language: English

Exrait

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 Doe udit 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's 941's  144,697  128,825  141,520  161,502  576,544  49,738

Commissions Company car Source 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