Audit Form Due Date: 10/20/2015 1 2 3

EXAMPLE

1 Business Information

Berkshire Hathaway GUARD P.O. Box A-H | 16 S. River Street

Wilkes-Barre, PA 18703-0020 570-825-9900 (Toll-Free 800-673-2465)

FAX 570-823-2059

Audit Form

Due Date: 10/20/2015

Policy Number: BIWC437962 Policyholder Name: Bill's Service Station

Report Period: 06/03/2003 to 06/03/2004

Business Type:

Corporation

LLC

Partnership

Sole Proprietorship

Other _______________

Federal Employer's ID Number (FEIN): 12-3456789

Is the information listed above correct?

Yes

No

If not, make needed corrections.

Provide a detailed description of your business operations. If necessary, continue on another sheet of paper.

Gas station with convenience store and automobile repair

2 Audit Contact

Name: Bill Smith Phone: (555) 555-1234

Extension:

Title: Owner Fax: (555) 555-1234

E-mail: b-s-s@

3 Ownership

Sole Proprietor, Partner, or Corporate Officer Information: Please describe specific job duties. For example, "floor supervisor, carpentry work" is acceptable while "owner, oversees business" is not.

Name and Title

Exact Job Duties

Gross Wages*

Bill Smith, Owner

Sales, management, mechanic work, and register operation

$ 33,000.00

$

$

$

4 Employees

Employee Information. If necessary, attach pages or supply a payroll summary.

Name and Title

Detailed Description of Job Duties and Responsibilities

Gross Wages & Overtime

Overtime*

Wages

Henry Meyers Automobile Mechanic

Performs minor repair and service work to automobiles, such as: tune-ups, oil changes, and minor electrical and engine work

$ 31,800.00

$ 800.00

Steven Miller Clerk / Service Attendant

Waits on customers, pumps gas, collects money, and performs general cleaning of store area

$ 13,000.00

$

David Jones Clerk / Service Attendant

Waits on customers, pumps gas, collects money, and performs general cleaning of store area

$13,000.00

$

Ronald Fenton Clerk / Service Attendant / Mechanic

Waits on customers, pumps gas, collects money, and performs minor repair and service to automobiles

$ 17,932.00

$

Wendy Smith Secretary

Maintains financial reports, handles correspondence, and answers the telephone; works in a seperate office from the register and garage

$ 9,885.00

$

$

$

$

$

$

$

$

$

$

$

*Gross wages represent the total paid to each person during the policy term before taxes, including commissions and bonuses.

Berkshire Hathaway GUARD P.O. Box A-H | 16 S. River Street

Wilkes-Barre, PA 18703-0020 570-825-9900 (Toll-Free 800-673-2465)

FAX 570-823-2059

5 Subcontractors

Audit Form

(continued)

Due Date: 10/20/2015

Policy Number: ABWC123456

Did you use subcontractors during the policy term?

Yes

No

If yes, list below. Any individual or business that assists in providing a product or service to your customer but is not included in your tax returns as an employee (compensated by check or cash) would be considered a subcontractor. A subcontractor may work for another organization or may be independent. If necessary, attach additional pages.

Name or Business Name Main St Auto Glass

Job Duties Replaces broken glass and mirrors

Total Amount Paid $ 2,500.00

$

$

$ $ Attach your most recently filed 1099s (if any), the 1096, and valid certificates of Workers' Compensation (if any).

6 Tax Documentation

Payroll Verification: Attach copies of the most recent four quarters of your: IRS Form 941: Employer's Quarterly Federal Tax Returns OR State Unemployment Tax Forms

7 Statement

Any person who makes, or causes to be made, any knowingly false or fraudulent material statement or representation with the intent to defraud or deceive any insurance company regarding the proper calculation of premium, including (but not limited to) the amount of payroll or employee job duties or other facts relevant to the proper classification of payroll, commits a fraudulent insurance act, which is a crime and may subject such person to criminal or civil penalties.

I certify the information on this document to be complete and accurate.

Signature

Date

Premium Audit Checklist REMINDER: Be sure you have included:

Audit Contact Information (name and phone number) Subcontractor Forms (all 1099s, 1096, and Certificates of Insurance for the policy period) Tax Documentation (IRS Form 941 or State Unemployment Quarterly Returns for the most recently completed four quarters)

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