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 premiumaudit@churchmutual.com.

Today's date:
*Account number: (requires 7 digits): Note: If your account number appears as 6 digits, preface with 0.
*Policy number: (requires 6 digits): 0 7 -
*Policy period start: (mm/dd/yyyy)
*Policy period end: (mm/dd/yyyy)
*Insured name:
*Street Address of organization:
*City:
*State:
*ZIP:
*Contact person:
*Title:
*Daytime phone: (##########) Enter only numbers
Ext:
*Email:
Website:
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 +
*YES, I hereby certify that the information provided is a true statement of gross earnings paid to all employees for the audit period.
Any new locations added during the audited term? If so, please enter in the Comments box below, the new full physical location addresses, the number of employees for each new location, and the intended building use (i.e. daycare, church, camp)
Comments:
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.

File Upload 1:
File Upload 2:
File Upload 3:
File Upload 4:
File Upload 5:
A print-ready version of this form will be presented after you click "Submit Audit for Processing" below.
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Workers Compensation Payroll Audit

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#	(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)
Have questions? View a Sample Audit. All fields required.
1			+