Instructions for Workers Compensation Mail Audits

Use the information below to help you fill out the specific sections of your audit form.

But first, click on the link below to see if the any state or special regulations apply to your business:

State and Special Reporting Rules

If you have any questions, please call our service center at 1-800-422-6340.

Completing Your Audit Form

Step 1 – Description of Business Operations
Step 2 – Owner's Section
Step 3 – Classification Section
Step 4 – Contact Information

Step 1 – Description of Business Operations

Please present a clear picture of your business operations. If you have multiple entities, please describe each one. If there isn't enough space, please write a full description on a separate sheet of paper, and attach it to the document. Here are some examples:

Example 1: "Carpentry operations. We do interior finish carpentry work only. We do not do any rough or framing carpentry."

Example 2: "Family-style restaurant. Table service is provided. There are no alcohol sales."

Example 3: "Manufacturers' representative for plumbing supplies. No warehousing or stocking of products. All items drop shipped by manufacturer."

In the "Are you operating as:" section, indicate the organizational structure of your business (e.g. Individual, Partnership, Corporation, Other – please explain).

Step 2 – Owner's Section

Owner/Officer Name	List all executive officers, owners, and partners.
Title	State the corresponding title for each person you list.
% Of Stock Owned	Indicate the amount of stock owned by each officer.
Type of Work Performed	Please be specific. Avoid terms such as "manager" or "administration." Describe the actual work duties performed by each person. For example, indicate if an individual is a supervisor of a work crew, in charge of outside sales, or has office duties. If the individual splits duties between operations, give the percentage of time spent in each activity.
Owner/Officer Gross Payroll	Report each person's total gross payroll. This includes payroll, commissions, bonuses, pay for overtime, piece work, holidays, vacations, and sickness, value of meals and lodging, and other substitutes for money.

Step 3 – Classification Section

When you purchased your policy, you estimated the original premium (deposit) based on projected total gross payroll amounts (less allowable deductions) by classification. Your policy may have one or more classifications assigned to it, depending on the type of business you operate. Please report total gross payroll by classification in the TOTAL GROSS PAYROLL column.

Total Gross Payroll

This is commonly called remuneration. Report total gross wages, commissions, bonuses, pay for overtime, piece work, holidays, vacations and sickness, value of meals and lodging, and other substitutes for money. Do not make deductions for 401k or similar tax-reducing plans.

Important: Do not include Executive Officer payroll in this section. We will obtain this information from the payroll you reported in the Owners Section. Officers and owners are subject to special minimums and maximums that vary by state. There are also potential signed inclusion or exclusion forms that we must verify and take into account. These could influence the total amount for each classification.

In the OVERTIME WAGES ONLY column, please report total overtime paid (if any) by classification. Please indicate if this was "double time". If there is no indication, we will proceed on the assumption that it is "time and a half".

If parts of your business operations are not described by these class codes (such as operations started during the policy term), please provide the total amounts for these operations.

Class Code	These are the classes we assign to your business operations.
Class Code Description	This is the corresponding description for each classification on the policy.
Total Gross Payroll	Report total gross wages, commissions, bonuses, pay for overtime, piece work, holidays, vacations, and sickness, value of meals and lodging, and other substitutes for money for all employees EXCEPT OFFICERS. Do not make any deductions for 401k or similar tax-reducing plans.
Overtime Wages Only	Report total overtime wages (if any) for each class code listed. We will deduct the premium portion of those wages from each classification total.

Include subcontractors/independent contractors who do not carry their own insurance, and work under your direction and control, as your employees. Report their earnings or labor costs in this section by the type of work they perform.

Step 4 – Contact Information

Please provide your contact information, including your email address, then sign and date the form.

Finished?

Once you complete and sign your form either:

• Fax it to us at (425)-556-4067 OR
• Mail it using the enclosed pre-addressed envelope

Questions?

We're happy to help. Please contact your agent or call us at 1-800-422-6340.