Carrier
Test Insurance Company
111 Main Street
Any City, AL   35801
Agent
MS Ins Agcy Inc
Policy Information
HAZ II 1234-567
Hazard II Garage Liability
12/25/2005 to 12/25/2006
AuditID: 184477
Audit Method: Physical
Audit Complete Type: Regular 		Insured Name and Address
XYC Service Station
123 Any St
Marion, MS   39342 		Completed By
Keith West
Wilkinson Insurance Services
5650 Sanderson Street Suite Q
Huntsville, AL   35805
Date Completed: 12/07/2006
FA Version: 3.0.5232 PID: 26
Description of Operations ... Audit 184477 ... Entity: XYC Service Station

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

Legal Entity:  INDIVIDUAL

The insured is operating a sole proprietorship in Marion, MS. The business of the insured is a service station that also sells gasoline, candy, lottery tickets, cokes, cigarettes, normal staple items, etc. The insured pumps gas as well as performs automobile service. They perform oil changes, tune-up’s, repair brakes and tires, etc. They are not doing major engine overhaul work. The insured had eight employees not including the owner.

Premium O/T was not since the employees are subject to a $100/week cap and the premium O/T has no bearing on exposure for this type of policy.

The insured did not use subcontractors.

The owner of the company is John Doe who is active in the business as the store manager and has been included in the garage liability at the maximum of $5,200.


Exposure Summary ... Audit 184477 ... 06/01/2004 to 06/01/2005 ... Policy HAZ II 1234-567

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

State Code Classification   Premium Basis Exposure
MS HAZII Hazard II Garage Liability   Payroll 28,863


Principal’s Information ... Audit 184477 ... Entity: XYC Service Station

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

John Doe Owner Included
Start/End Dates: 06/01/2004 to 06/01/2005 Min: 5,200 Max: 5,200
INDIVIDUAL MS HAZII Hazard II Garage Liability Payroll
Audit Period: 06/01/2004 to 06/01/2005 Total Amount: 0 Included At: 5,200
          All Duties


Exposure Recap ... Audit 184477 ... 06/01/2004 to 06/01/2005

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

State Code Classification Premium Basis
MS HAZII Hazard II Garage Liability   Payroll
    Emp 1, 52 Weeks  -Garage   5,200
    Emp 2, 52 Weeks  -Garage   5,200
    Emp 3, 46 Weeks  -Garage   4,600
    Emp 4, 34 Weeks  -Garage   3,400
    Emp 5, 38 Weeks  -Garage   3,800
    Emp 6, 4 Weeks  -Garage   370
    Emp 7, 4 Weeks  -Garage   336
    Emp 8, 8 Weeks  -Garage   757
    *John Doe  -All Duties   5,200
    Total:   28,863


Worksheet Stacked #1 ... Audit 184477

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

Date Gross Col 3 Col 4 Col 5 Col 6
  Payroll HAZII Hazard II Garage Liability HAZII Hazard II Garage Liability HAZII Hazard II Garage Liability HAZII Hazard II Garage Liability
  Fax/Phone Emp 1, 52 Weeks Emp 2, 52 Weeks Emp 3, 46 Weeks Emp 4, 34 Weeks
    MS MS MS MS
6/1-6/1: 59,663 20,286 11,416 12,016 8,523
    [-15086] Excess Wages [-6216] Excess Wages [-7416] Excess Wages [-5123] Excess Wages
  59,663 5,200 5,200 4,600 3,400

Date Col 7 Col 8 Col 9 Col 10 Col 11
  HAZII Hazard II Garage Liability HAZII Hazard II Garage Liability HAZII Hazard II Garage Liability HAZII Hazard II Garage Liability HAZII Hazard II Garage Liability
  Emp 5, 38 Weeks Emp 6, 4 Weeks Emp 7, 4 Weeks Emp 8, 8 Weeks John Doe
  MS MS MS MS MS
6/1-6/1: 5,959 370 336 757  
  [-2159] Excess Wages        
  3,800 370 336 757  

General Liability Verification ... Audit 184477 ... 06/01/2004 to 06/01/2005

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

State Code Classification                            Exposure
MS HAZII Hazard II Garage Liability   Payroll 28,863
    Name (* Principal) Adjustment Description Adjustment
    Emp 1, 52 Weeks [-15086] Excess Wages 15,086
    Emp 2, 52 Weeks [-6216] Excess Wages 6,216
    Emp 3, 46 Weeks [-7416] Excess Wages 7,416
    Emp 4, 34 Weeks [-5123] Excess Wages 5,123
    Emp 5, 38 Weeks [-2159] Excess Wages 2,159
    *John Doe Under Inclusion Minimum (5,200)
        ---------------
      Adjustments Total: 30,800
        ---------------
      Audit Total: 59,663


Worksheet Gross Total:           59,663      Verification Source Total:           59,663


General Information ... Audit 184477 ... Policy HAZ II 1234-567

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

Insured:
XYC Service Station
123 Any Street Marion, MS 39342
Entity: XYC Service Station
Phone: 601-555-5555
Records obtained from:
John Doe
123 Any Street Marion, MS 39342

----------------Verification Source Record-----------------

Entity: XYC Service Station
Verification Source Record: Fax/Phone
Employer’s Federal ID No.: 12-3456789


1st Quarter 2005: 13,108  
2nd Quarter : 0  
3rd Quarter 2004: 16,179  
4th Quarter 2004: 18,306  
Subtotal: 47,593  
Adjustment Dates Description Adjustment Amount
06/01/2004 to 06/30/2004   4,668
04/01/2005 to 04/30/2005   4,095
05/01/2005 to 05/31/2005   3,307
Adjusted Subtotal:   59,663
Grand Total: 59,663  


General Liability Checklist
Policy number and policy period match the request? YES General ledger or checkbook reviewed? N/A
15 day rule observed for the audit period? YES Invoices reviewed for materials credit for uninsured subs? N/A
If employees are lumped, did you provide # of employees? N/A G/L, did you include one principal? YES
Was the total subcontractor cost considered? N/A Did the subcontractor(s) have adequate liability limits? N/A
Were the executives, partners, or individual included? YES Are drivers and chauffeurs excluded? N/A
Were there leased employees? N/A Was there equipment rental to others? N/A
Were there any additional locations? NO Were there any new products manufactured or sold? N/A
General Information Checklist
Are the records computerized? SEE NOTES What is the condition of the records? POOR
Were payroll journal records examined? NO Were general ledger records examined? NO
Was the check book examined? NO Were income tax return records examined? NO
Were cash disbursement records examined? NO Were S/S Returns examined? NO
Were cash receipt records examined? N/A Were U/C Returnes examined? NO


Notes To Audit Department ... Audit 184477 ... Policy HAZ II 1234-567

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

PHONE AUDIT

Test Insurance Company Any City, AL
XYC Service Station Marion, MS
XYC Service Station  
Auditor: Keith West Wilkinson Insurance Services, Inc. (256) 880-2900  


Percent difference between actual and estimated exposures (negative if est. > act.):
State Code Classification Prem. Basis Extra ID Percent Difference
MS HAZII Hazard II Garage Liability Payroll   39%


          Notes To Audit Department-----------------------------------

          The gross receipts were $620,107.

          

          The insured stated that the increase in exposure was because he added employees, but he is now back

          down to only three employees.

          

          The physical address of the insured is 123 Any Street, Marion, MS 39342.


Progress Report ... Audit 184477 ... Entity: XYC Service Station

Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005

Z 9999 Test Insurance Company Any City, AL  
Insured: XYC Service Station Marion, MS  
Entity: XYC Service Station Policy period: 05/28/2004 to 05/28/2005  
Policy No(s): HAZ II 1234-567    
Auditor: Keith West Wilkinson Insurance Services, Inc. (256) 880-2900  
Attempt 1 Next attempt on: Audit received on: 06/02/2005
  Attention: Audit Department Agency:
Remarks
9:45 am There was no answer and no answering machine when I tried to contact the
insured.


End of Report -- Audit No: 184477; Policy No(s): HAZ II 1234-567; Policy Period: 05/28/2004 to 05/28/2005