Premium Audit Form - Service Insurance Companies

Business Insurance Information * indicates required fields

Insured Business Name*

Insured Business Address*

Policy Number*

Audit Contact Name*

Audit Contact Phone Number*

Audit Contact Email*

Business Details

Business Ownership Individual Listing*

First and Last Name

Job Title

Ownership %

Gross Wages

Describe Business Operations*

List of locations*

Street Address

City

State

Payroll at Location

Do you use subcontractors?*

Yes

No

Comments

Document Upload

Upload Federal (941)/State quarterly returns that correspond to your policy period*

Drop files here or

Accepted file types: pdf, xlsx, xls, jpeg, jpg, Max. file size: 20 MB, Max. files: 10.

Please upload employee payroll report, subcontractor payroll report for the policy period, 1099s, Certificates of Insurance, and/or Independent Contractor Waivers for each subcontractor*

Drop files here or

Accepted file types: pdf, xlsx, xls, jpeg, jpg, Max. file size: 20 MB, Max. files: 10.

Name

This field is for validation purposes and should be left unchanged.