Self-Audit Form
Please complete this entire form. You can Upload Documents Below. After submitting you will receive a confirmation email with a copy for your records.
Basic Company Info
Company Name
*
Policy Number
*
Effective Date
*
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Month
-
Day
Year
Date
Expiration Date
*
-
Month
-
Day
Year
Date
Audit Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Description of Business Operations
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Is farming apart of your business operations?
Yes
No
Was housing provided for H2A employees during the policy period?
Yes
No
How many months did the H2A employees live in the provided housing?
How many housing units were provided?
What is the rent charged or the fair market value of the rent for the housing provided?
Legal Status
*
Corporation
LLC
Partnership
Individual
Other
Officers
Please list all officers, their title, gross payroll and work performed.
Officer Name
Title
Gross Payroll
Work Performed
1.
Employees
Please list all company employees, gross payroll, overtime, tips and work performed. A portion of overtime may be deducted from your payroll. If you have experienced changes in your business operations or reassigned employees to different duties as a result of COVID-19, please provide current duties and payroll amounts below. If furloughed, please separate their payroll.
Employee Name
Gross Payroll
Overtime
Tips
Class Code
Work Performed
1.
Subcontractors
Please list all subcontractors / independent contractors, amounts paid, the work they performed and if the amounts paid to the sub included labor, materials and/or equipment. If the amount you paid the uninsured subcontractor includes both labor and materials, it is important that you provide an invoice or receipt for the materials; otherwise, we will calculate the premium based on the total amount paid to the uninsured subcontractor in accordance with the NCCI rules. In some cases, you may hire a subcontractor to perform work for you who does not have their own workers' compensation insurance. The UNINSURED subcontractor will be covered under your policy for the project performed during the policy term.
Sub Name
Amount Paid
Did that Amount Include Labor, Materials, and/or Equipment?
Work Performed
Certificate of Insurance Obtained
1.
Labor Only
Materials Only
Equipment Only
Labor & Materials
Labor & Equipment
Materials & Equipment
Labor, Materials, & Equipment
Please upload any certificates of insurance or invoices obtained for the subcontractors/independent contractors listed above. Please be sure that the certificate covers the date(s) they performed work for you.
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Supporting Documentation Upload
Please upload copies of your 4 most recent Federal 941s OR State Quarterly Tax Reports, Schedule C, Federal 943s or 1099s, 1096 Summary, Payroll Summary or any supporting documentation.
*
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