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Mail Audit
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Insured's Name
Aqua Conditioning
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Policy Number
Mail Audit
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Policy Expiration Date
02/27/2010
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| Entity |
Corporation
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Principals (Required):
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Principals (Required-Click the Edit button to enter the Principal information)
| Name |
Title |
Active (yes or no) |
Actual work each performs |
Total gross wages for the period-Including any commissions & bonuses |
Location Number |
Class |
| W. Baker |
Pres |
Yes |
All Work |
56500 |
1 |
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Please number and list all business locations by address
#1 717 W Main St, Huntsville, AL 35805
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Describe your business operations
Sale and service water equipment
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***Employees Only. Do not include owners or officers below.***
Itemize all employees (Full-time, Part-time, Janitorial) and any cash or casual laborers used. Gross wages should include all Bonuses and any Commissions paid during the audit period shown above.
If you have more than 10 employees, please group them by job duty.
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| Do you have any payroll paperwork (941's, SUTA's, or other Payroll reports) to attach? (If so, please attach) |
No
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Employees (Required-Click the Edit button to enter the Employee information. Enter NONE in the first block if not applicable)
| Employee Name |
Actual work each performs |
Total Gross Wages (including all overtime) |
Overtime Wages |
Location Number |
Class |
| Mike Smith |
Service tech |
22850 |
7.88 |
1 |
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| Tara Jones |
Secretary |
1855 |
0 |
1 |
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Describe the goods, products, or merchandise your business sells
Water treatment equipment
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Did you have sales of:
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| **Water softening chemicals? |
Yes
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| **Water Softening Equipment which is not to be used in connection with the installation, service or repair operations you perform? |
Yes
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| Do you rent any Water softening equipment? |
No
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Describe any installation, service, or repair work you perform
Install RO filters, softeners and DI treatment equipment
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Report the names of those individuals or owners who leave the business premises in the performance of their jobs:
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Required (Click the Edit button to enter the Required information. Enter NONE in the first block if not applicable)
| Name |
Reason for leaving the business premises |
Class |
| w.scott mccollum |
sales, service repair equipment |
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| mike bradshaw |
exchange DI tanks, service equipment, delivery of equipment |
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Report your total gross receipts, before deductions, during the audit period ($)
209000
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| Did your business experience any significant changes during this policy period? |
No
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***Subcontractors Questionnaire***
Attach certificates of insurance for all subcontractors detailed below. Without this evidence, we must classify and rate the subcontractors work as if it was performed by your own employees. Construction contractors, hired trucks, musicians, and entertainers are to be included in this section.
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| Did any of your subcontractors have their own General Liablity insurance? (If so, please attach their certificates of insurance - make sure to provide 2, if necessary to cover your policy period) |
No
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Subcontractors (Required-Click the Edit button to enter the Subcontractor information. Enter NONE in the first block if not applicable)
| Name of Subcontractor |
Type of work performed |
Total Contract Cost |
Did they have employees (yes or no)? |
Did they provide the materials (yes or no)? |
Did they have their own general liability insurance? |
Location Number |
Class |
| none |
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***Supporting Documentation and Contact Information***
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Please report all states that you performed work in during this audit period
AL
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Insured's Federal ID Number
731267xxx
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Insured's State Unemployment ID Number
01-2533xxx
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Total number of employees during the audit period, including terminated employees, but excluding owners
3
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If you were required to complete Federal IRS 941 Quarterly Reports or your State UC-3 Unemployment Quarterly Reports, please include copies of the four reports closest to the audit period.
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For our records, please provide the following information:
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Business phone number
256-555-1000
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Business fax number
256-555-1001
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E-mail address
aqua@bellsouth.net
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***If you return this form via fax, email, or online, it is not necessary to mail this form.***
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Name of the person completing this form (Please Print)
W Baker
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Signature (Type full name if filling out online)
W Baker
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Title
President
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Phone number
256-555-1000
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Date
3/12/10
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| Authorization of Release: Do you want a copy of the completed audit released to your insurance agent? |
Yes
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***If filling this out online, please be sure to click the "Save" button to save your form and then click "Finish Audit Forms" at the top of this screen to submit your information. All sections with a PINK background must be completed before the Finish button can be clicked.***
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