Workers’ Compensation Payroll Audit

If you have attachments, we recommend you print the Workers’ Compensation 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 to (715) 539-4721.

If you need help or have any questions on this audit, call (800) 554-2642, Option 4, Extension 4000, or email us at premiumaudit@churchmutual.com.

*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
# of weeks worked (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 +
 
Yes No
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Church Mutual Insurance Company
P.O. Box 357 | 3000 Schuster Lane | Merrill, WI 54452-0357
Telephone (800) 554-2642 or (715) 536-5577

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