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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