Workers Compensation Payroll Audit

If you need help or have any questions on this audit, call (800) 554-2642, Extension 4000, or email us at

*Required fields

Note: If your account number appears as 6 digits, preface with 0.
0 7 -
Have questions? View a Sample Audit.
All fields required.
# (W-2 holder)
Name of employee 1099 contractor or uninsured contractor
Job title Gross payroll
for audit period
(E.g., "Yes", "Included in gross payroll," annual dollar amount or number of weeks)Rent-free living quarters or housing allowance
(Enter text or dollar amount)
(E.g., total dollar value of meals, number of meals or number of weeks meals were offered) Meals (Camps)
(Enter text or dollar amount)
 1 +

Certificates of insurance (optional):

Attach certificates of insurance for any contractors used during the audit period.
(.jpg, .xls, .xlsx, .doc, .docx, .pdf only. Approximately 5mb and under file size recommended.)

Do NOT include 941 statements, employee payroll records, housing verifications, check registers etc.

A print-ready version of this form will be presented after you click "Submit Audit for Processing" below.
Print This Audit Submission
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Church Mutual Insurance Company, S.I. (a stock insurer)
P.O. Box 357 | 3000 Schuster Lane | Merrill, WI 54452-0357
Telephone (800) 554-2642 or (715) 536-5577

© 2024 Church Mutual Insurance Company, S.I. All rights reserved. Protecting the Greater Good is a registered trademark of Church Mutual Insurance Company, S.I.

Church Mutual is a stock insurer whose policyholders are members of the parent mutual holding company formed on 1/1/20. S.I. = a stock insurer.