PAYROLL AUDIT REPORT OF WAGES
If you have attachments, we recommend you print the Payroll Audit Report of Wages and mail all documents together.
If more space is needed to provide information, please complete additional pages, print, and submit via mail or via
FAX (715) 539-4721.
If you need help or have any questions on this audit, call (800)554-2642, Option 4, Extension 4000, or e-mail us at premiumaudit@churchmutual.com.
*Required fields.
*Required fields.
Today's Date: May 17, 2012
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Account Number:
(requires 7 digits)
Note: If your account number appears as 6 digits, preface with 0.
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Policy Number:
(requires 6 digits)
0 7 -
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Policy Period:
Month
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Date
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Year
2010
2011
2012
2013
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To:
Month
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Date
01
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Year
2010
2011
2012
2013
2014
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Insured Name:
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Street Address:
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City:
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State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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Zip:
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Contact Person:
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Title:
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Daytime Phone:
(xxx-xxx-xxxx)
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E-Mail Address:
Web Site:
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Please enter number of
ALL
employees:
and then click here to list employees and payroll information
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YES, I hereby certify that the information provided is a true statement of gross earnings paid to all employees for the audit period.
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Is this Audit complete?
Yes
No
(If No, explain below in the Comments box what additional information you plan to provide.)
Comments:
A print-ready version of this form will be presented after you click "Submit Audit for Processing" below.
