formGenie - Sample Insurance Form.

Sample Insurance Form
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INS. CO:
INSURED:
ADDRESS:

POLICY NUMBER:
POLICY PERIOD:
AUDIT PERIOD:

AUDIT SUMMARY

STATE CODE CLASSIFICATION LIABILITY WORKERS
COMP

TOTALS
(For verification Purposes Only

SOURCE OF INFORMATION

COMPANY NAME:

INDIVIDUAL/POSITION:

ADDRESS:

PHONE NO:

PAYROLL VERIFICATION

QTR
QTR
QTR
QTR
SUB-TOTAL

ADJUSTMENTS
ADD:

LESS:


TOTAL AUDITABLE PAYROLL

SOURCE OF DATA
Payroll Book
Cash Book
Check Book
General Ledger
General Journal

VERIFICATION
S/S RETURNS
U/C RETURNS
INCOME TAX
FINANCIAL STATEMENT

CONDITION
GOOD FAIR POOR

SUB-CONTRACTOR
YES   NO

ADJUSTMENT
Yes No
   Overtime
   Min/Max Wage
   Lodging/Meals
   Tips
   Bonus
   Commissions
   Temp Labor
   Unpaid Relatives
   Aircraft
   401-K/IRA
   Deferred Wages
   Class. Changes

COOPERATION
GOOD FAIR POOR

LEGAL ENTITY

Sole Proprietor

Partnership

Corporation

Joint Venture

Other

Title

Name

Gross
Payroll

Amount
Included

Code No.

W.C.

LIAB

Description of Duties
Give % if more than one duty)

DESCRIPTION OF OPERATIONS:

Special Attention:

Classification Changes

Significant Exposure Variations

Change in Entity

Subcontractors

Uninsured Subs (Refer to Schedule)

Other (describe)

List of Subs Without COI left with Insured or Representative

Auditor: Email: Date:

FormGenie LLC. · PO BOX 1884 · Columbia, SC 29202 · P: 803.361.2963 · F: 815.461.6156