5650 Sanderson Street
Suite Q
Huntsville, AL 35805-1901

Z9999 - Test Insurance Company
111 Main Street
Any City, AL   35801


Transmittal for Audit ID: 184473


Policy Number(s)
WC 12-AB-1234-1		Insured Name and Address
XYZ Construction Inc
123 Any St
Nashville, TN   37208		Audit Period
05/30/2004
to
05/30/2005
Date Received
10/18/2005
Date Completed

Auditor No.
9
Billing Summary
Do Not Pay Invoice to Follow
Entered DateDescriptionAmountQuantityTotal
This audit was 0 billed0.000.000.00
Total:0.00


 

Wilkinson Premium Audit Manager Powered by AuSuM Systems
Carrier
Test Insurance Company
111 Main Street
Any City, AL   35801
Agent
Alpha Ins Agcy Inc
Policy Information
WC 12-AB-1234-1
Workers' Compensation
05/30/2004 to 05/30/2005
AuditID: 184473
Audit Method: Physical
Audit Complete Type: Regular 		Insured Name and Address
XYZ Construction Inc
123 Any St
Nashville, TN   37208 		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 184473 ... Entity: XYZ Construction Inc

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

Legal Entity:  CORPORATION

The insured is a corporation in Nashville, TN operating under the name of XYZ Construction Inc. The insured is a general contractor working for insurance companies performing residential restoration work. They are doing fire, water, and wind damage restoration. This type of work includes cleaning up homes after these types of disasters have occurred. Field employees could perform a variety of tasks, depending on the damage incurred, including tearing out old flooring (carpet, tile, wood, etc.) and replacing with new, tearing out damaged drywall and replacing with new, painting, etc. In this period field employees performed primarily painting and carpentry work, no interchange of labor. The painting employees were classified under the 5474 class code and all carpentry related work was placed under the 5645 class code.

Employees working in the offices of the insured have been placed in the 8810 class code. These workers are performing various tasks such as receptionist, bookkeeping, scheduling, etc.

Several employees are included in the 8742 class code as outside estimators. They are performing job estimates and have travel responsibilities included within the regular scope of the job duties.

The insured also used a number of insured subcontractors and uninsured subcontractors. Certificates of insurance were reviewed for all insured subs and all have been excluded per verification of their COI’s. Payments made to the insured subs were all covered within the COI dates. All uninsured subs were included in the appropriate class code per their duties. One performed glass installation work while the others were general carpentry laborers.

Officer 1 is the President and is excluded per endorsement. Officer 2 is the Secretary/Treasurer and is excluded per endorsement. Both officers are active in the business overseeing all operations, visiting job sites on a regular basis to determine job progress, provide indirect supervision through the job site foremen, etc.


Exposure Summary ... Audit 184473 ... 06/01/2004 to 06/01/2005 ... Policy 12-AB-1234-1

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

State Code Classification   Premium Basis Exposure
TN 0042 Landscape gardening   Payroll 0
TN 5213 Concrete private residences construction - monolithic   Payroll 0
TN 5348 Tile, stone, mosaic or terrazzo work - inside   Payroll 0
TN 5474 Painting NOC   Payroll 188,096
TN 5645 Carpentry - detached dwellings   Payroll 85,384
TN 8742 Salespersons, collectors, messengers   Payroll 369,308
TN 8810 Clerical office employees   Payroll 208,164
  Subcontractors Exposure Summary ... 06/01/2004 to 06/01/2005
State Code Classification   Premium Basis Exposure
TN 5462 Glazier - away from shop   Payroll 2,446
TN 5645 Carpentry - detached dwellings   Payroll 8,369


Principal’s Information ... Audit 184473 ... Entity: XYZ Construction Inc

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

Officer 1 President Excluded
CORPORATION TN 41 EXCLUDED    
Audit Period: 06/01/2004 to 06/01/2005 Total Amount: 94,000 Included At: 0
          Operations mgr / visits job sites
Officer 2 S/T Excluded
CORPORATION TN 41 EXCLUDED    
Audit Period: 06/01/2004 to 06/01/2005 Total Amount: 52,200 Included At: 0
          Operations mgr / visits job sites


Exposure Recap ... Audit 184473 ... 06/01/2004 to 06/01/2005

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

State Code Classification Premium Basis
TN 0042 Landscape gardening   Payroll
        0
    Total:   0
TN 5213 Concrete private residences construction - monolithic   Payroll
        0
    Total:   0
TN 5348 Tile, stone, mosaic or terrazzo work - inside   Payroll
        0
    Total:   0
TN 5474 Painting NOC   Payroll
    Emp 1  -Painting   37,209
    Emp 10  -Painting   5,685
    Emp 11  -Painting   13,388
    Emp 12  -Painting   8,190
    Emp 2  -Painting   30,126
    Emp 3  -Painting   32,730
    Emp 4  -Painting   22,486
    Emp 5  -Painting   360
    Emp 6  -Painting   7,721
    Emp 7  -Painting   5,175
    Emp 8  -Painting   2,168
    Emp 9  -Painting   22,858
    Total:   188,096
TN 5645 Carpentry - detached dwellings   Payroll
    Emp 13  -Carpentry   23,007
    Emp 14  -Carpentry   31,493
    Emp 15  -Carpentry   28,986
    Emp 16  -Carpentry   1,898
    Total:   85,384
TN 8742 Salespersons, collectors, messengers   Payroll
    Emp 23  -Outside estimator   191,352
    Emp 24  -Outside estimator   94,000
    Emp 25  -Outside estimator   73,539
    Emp 26  -Outside estimator   10,417
    Total:   369,308
TN 8810 Clerical office employees   Payroll
    Emp 17  -Receptionist   20,661
    Emp 18  -Accounting   40,000
    Emp 19  -Secretary   52,497
    Emp 20  -Checks/paperwork   37,625
    Emp 21  -A/R   25,900
    Emp 22  -Payroll   31,481
    Total:   208,164
TN   EXCLUDED    
    *Officer 1  -Operations mgr / visits job sites   94,000
    *Officer 2  -Operations mgr / visits job sites   52,200
    Total:   146,200
Subcontractors Exposure Recap ... Audit 184473 ... 06/01/2004 to 06/01/2005

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

State Code Classification Premium Basis
TN 5462 Glazier - away from shop   Payroll
    Sub 6   2,446
    Total:   2,446
TN 5645 Carpentry - detached dwellings   Payroll
    Sub 10   7,682
    Sub 13   90
    Sub 7   597
    Total:   8,369


Worksheet Stacked #1 ... Audit 184473

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

Date Gross Col 3 Col 4 Col 5 Col 6
  Payroll EXCLUDE EXCLUDE 5474 Painting NOC 5474 Painting NOC
  Computer Reports Officer 2 Officer 1 Emp 1 Emp 2
  TN TN TN TN TN
06/1-06/30: 65,746 4,350 4,667 2,545 2,555
07/1-09/30: 194,480 13,050 14,000 9,415 7,711
10/1-12/31: 435,367 13,050 52,000 10,490 8,170
01/1-3/30: 180,819 13,050 14,000 8,561 6,719
04/1-05/31: 120,740 8,700 9,333 6,198 4,971
  997,152 52,200 94,000 37,209 30,126

Date Col 7 Col 8 Col 9 Col 10 Col 11
  5474 Painting NOC 5474 Painting NOC 5474 Painting NOC 5474 Painting NOC 5474 Painting NOC
  Emp 3 Emp 4 Emp 5 Emp 6 Emp 7
  TN TN TN TN TN
06/1-06/30: 2,352 1,806 360 1,946 1,671
07/1-09/30: 8,212 7,039   5,775 3,504
10/1-12/31: 9,032 6,753      
01/1-3/30: 7,328 6,671      
04/1-05/31: 5,806 217      
  32,730 22,486 360 7,721 5,175

Date Col 12 Col 13 Col 14 Col 15 Col 16
  5474 Painting NOC 5474 Painting NOC 5474 Painting NOC 5474 Painting NOC 5474 Painting NOC
  Emp 8 Emp 9 Emp 10 Emp 11 Emp 12
  TN TN TN TN TN
06/1-06/30: 2,168 384      
07/1-09/30:   4,616 1,224    
10/1-12/31:   6,586 4,461 1,312  
01/1-3/30:   6,240   7,244 4,221
04/1-05/31:   5,032   4,832 3,969
  2,168 22,858 5,685 13,388 8,190

Date Col 17 Col 18 Col 19 Col 20 Col 21
  5645 Carpentry - detached dwellings 5645 Carpentry - detached dwellings 5645 Carpentry - detached dwellings 5645 Carpentry - detached dwellings 8810 Clerical office employees
  Emp 13 Emp 14 Emp 15 Emp 16 Emp 17
  TN TN TN TN TN
06/1-06/30: 1,913 2,538 2,314   1,598
07/1-09/30: 6,044 8,461 7,567   5,075
10/1-12/31: 5,919 7,010 7,702   5,755
01/1-3/30: 4,981 7,289 6,510   4,778
04/1-05/31: 4,150 6,195 4,893 1,898 3,455
  23,007 31,493 28,986 1,898 20,661

Date Col 22 Col 23 Col 24 Col 25 Col 26
  8810 Clerical office employees 8810 Clerical office employees 8810 Clerical office employees 8810 Clerical office employees 8810 Clerical office employees
  Emp 18 Emp 19 Emp 20 Emp 21 Emp 22
  TN TN TN TN TN
06/1-06/30: 3,167 4,000 3,750 1,994 2,500
07/1-09/30: 9,500 12,999 11,250 6,288 7,500
10/1-12/31: 11,500 14,499 13,250 7,006 8,981
01/1-3/30: 9,500 11,999 9,375 5,853 7,500
04/1-05/31: 6,333 9,000   4,759 5,000
  40,000 52,497 37,625 25,900 31,481

Date Col 27 Col 28 Col 29 Col 30 Col 31
  8742 Salespersons, collectors, messenger 8742 Salespersons, collectors, messenger 8742 Salespersons, collectors, messenger 8742 Salespersons, collectors, messenger 0042 Landscape gardening
  Emp 23 Emp 24 Emp 25 Emp 26  
  TN TN TN TN TN
06/1-06/30: 4,167 4,667 4,167 4,167  
07/1-09/30: 12,500 14,000 12,500 6,250  
10/1-12/31: 153,852 52,000 36,039    
01/1-3/30: 12,500 14,000 12,500    
04/1-05/31: 8,333 9,333 8,333    
  191,352 94,000 73,539 10,417  

Date Col 32 Col 33 Col 34 Col 35 Col 36
  5213 Concrete private residences constru 5348 Tile, stone, mosaic or terrazzo wor      
           
  TN TN      

Subcontractors ... Audit 184473 ... Entity: XYZ Construction Inc

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

Sub 1 Granite State    
  WC8164271 Policy period: 06/26/2004 to 06/26/2005 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  36,906 Materials:  0 Exposure:  36,906


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 10 Carpentry    
  5645 Carpentry - detached dwellings Payroll Liability Lim:  0
  Contract period: 06/01/2004 to 06/01/2005 Cost:  15,314 Materials:  7,632 Exposure:  7,682


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 11 Liberty Mutual/WoCompAR    
  WC5-35S-351966-014 Policy period: 04/29/2004 to 04/29/2006 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  16,971 Materials:  0 Exposure:  16,971


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 12 Builders Mutual Insurance    
  WC24281102 Policy period: 07/25/2004 to 07/25/2005 Audit State:  
        Liability Lim: 1,000,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  14,686 Materials:  0 Exposure:  14,686


Cost and Contract Period Detail  
06/01/2004 14,686         
06/01/2005 0         


Sub 13 Carpentry    
  5645 Carpentry - detached dwellings Payroll Liability Lim:  0
  Contract period: 06/01/2004 to 06/01/2005 Cost:  160 Materials:  70 Exposure:  90


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 14 Bridgefield Casualty Insurance    
  19901702 Policy period: 09/01/2004 to 07/19/2005 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  101,641 Materials:  0 Exposure:  101,641


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 15 Builders Mutual Insurance    
  20012813 Policy period: 09/01/2004 to 09/01/2005 Audit State:  
        Liability Lim: 500,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  260 Materials:  0 Exposure:  260


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 16 Builders Mutual Insurance    
  001000032429104 Policy period: 09/19/2004 to 09/19/2005 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  9,218 Materials:  0 Exposure:  9,218


Cost and Contract Period Detail  
06/01/2004 9,218         
06/01/2005 0         


Sub 17 Commerce & Industry    
  WC7834707 Policy period: 07/01/2004 to 07/01/2005 Audit State:  
        Liability Lim: 500,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  150 Materials:  0 Exposure:  150


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 18 State Auto Insurance    
  WCP9635706 Policy period: 05/01/2004 to 05/01/2006 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  750 Materials:  0 Exposure:  750


Cost and Contract Period Detail  
06/01/2004 750         
06/01/2005 0         


Sub 19 Union Insurance    
  WCA4169228 Policy period: 10/01/2004 to 10/01/2005 Audit State:  
        Liability Lim: 500,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  45,686 Materials:  0 Exposure:  45,686


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 2 Companion Property & Casualty    
  WC-7056078 Policy period: 12/01/2004 to 12/01/2005 Audit State:  
        Liability Lim: 1,000,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  1,000 Materials:  0 Exposure:  1,000


Cost and Contract Period Detail  
06/01/2004 1,000         
06/01/2005 0         


Sub 20 AON/ American Zurich    
  6ZZUB-3413B68 Policy period: 08/01/2004 to 08/01/2005 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  1,880 Materials:  0 Exposure:  1,880


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 3 Pennsylvania National Ins. Co.    
  WC9009727303 Policy period: 08/29/2004 to 08/29/2005 Audit State:  
        Liability Lim: 1,000,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  6,655 Materials:  0 Exposure:  6,655


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 4 Ace American    
  CA3691831 Policy period: 06/21/2004 to 06/21/2005 Audit State:  
        Liability Lim: 500,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  76,989 Materials:  0 Exposure:  76,989


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 5 Zurich    
  042896218 Policy period: 01/05/2005 to 01/05/2006 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  7,583 Materials:  0 Exposure:  7,583


Cost and Contract Period Detail  
06/01/2004 7,583         
06/01/2005 0         


Sub 6 Glass installation    
  5462 Glazier - away from shop Payroll Liability Lim:  0
  Contract period: 06/01/2004 to 06/01/2005 Cost:  4,892 Materials:  2,446 Exposure:  2,446


Cost and Contract Period Detail  
06/01/2004 4,892         
06/01/2005 0         


Sub 7 Carpentry    
  5645 Carpentry - detached dwellings Payroll Liability Lim:  0
  Contract period: 06/01/2004 to 06/01/2005 Cost:  1,194 Materials:  597 Exposure:  597


Cost and Contract Period Detail  
06/01/2004 0         
06/01/2005 0         


Sub 8 Hartford Fire Insurance Company    
  1560568-SDF Policy period: 03/18/2004 to 03/18/2005 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  5,645 Materials:  0 Exposure:  5,645


Cost and Contract Period Detail  
06/01/2004 5,645         
06/01/2005 0         


Sub 9 TWCIP    
  WC65465151 Policy period: 01/01/2005 to 01/01/2006 Audit State:  
        Liability Lim: 100,000
  Contract period: 06/01/2004 to 06/01/2005 Cost:  1,230 Materials:  0 Exposure:  1,230


Cost and Contract Period Detail  
06/01/2004 1,230         
06/01/2005 0         



Workers’ Compensation Verification ... Audit 184473 ... 06/01/2004 to 06/01/2005

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

State Code Classification                            Exposure/Adjustments
TN 0042 Landscape gardening   0
TN 5213 Concrete private residences construction - monolithic   0
TN 5348 Tile, stone, mosaic or terrazzo work - inside   0
TN 5474 Painting NOC   188,096
TN 5645 Carpentry - detached dwellings   85,384
TN 8742 Salespersons, collectors, messengers   369,308
TN 8810 Clerical office employees   208,164
TN   EXCLUDED   146,200
      Audit Total: 997,152


Worksheet Gross Total:           997,152      Verification Source Total:           997,152


End of Report -- Audit No: 184473; Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005


General Information ... Audit 184473 ... Policy 12-AB-1234-1

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

Insured:
XYZ Construction Inc
123 Any Street Nashville, TN 12345
Entity: XYZ Construction Inc
Phone: 615-123-4567
Records obtained from:
Jane Doe
123 Any Street Nashville, TN 12345

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

Entity: XYZ Construction Inc.
Verification Source Record: Federal 941 & State U/C
Employer’s Federal ID No.: 12-3456789


1st Quarter 2005: 180,819  
2nd Quarter 2005: 0  
3rd Quarter 2004: 194,480  
4th Quarter 2004: 435,367  
Subtotal: 810,666  
Adjustment Dates Description Adjustment Amount
04/01/2005 to 05/31/2005   120,740
06/01/2004 to 06/30/2004   65,746
Adjusted Subtotal:   997,152
Grand Total: 997,152  


Workers’ Compensation Checklist
Were there leased employees? NO Were bonuses included? N/A
Were employee contributions to benefit plans included? N/A Were commissions included? N/A
Was board and lodging included? N/A Were tips excluded? N/A
Were subcontractors used? YES Were contract drivers used? N/A
Was premium overtime deducted? NO Does the insured operate an aircraft? N/A
Is the legal entity correct? NO Are there any additional entities? See Notes
Are there any new operations? YES    
General Information Checklist
Are the records computerized? YES What is the condition of the records? GOOD
Were payroll journal records examined? YES Were general ledger records examined? YES
Was the check book examined? NO Were income tax return records examined? NO
Were cash disbursement records examined? NO Were S/S Returns examined? YES
Were U/C Returns examined? YES Were cash receipt records examined? YES
Were Certificates of Insurance examined? YES Were 1099 records examined? NO
What other records were examined? NONE All locations/addresses shown verified/discussed on audit? YES


Notes To Audit Department ... Audit 184473 ... Policy 12-AB-1234-1

Policy No(s): 12-AB-1234-1; Policy Period: 05/30/2004 to 05/30/2005

Test Insurance Company Any City, AL
XYZ Construction Inc Nashville, TN
XYZ Construction Inc  
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
TN 0042 Landscape gardening Payroll   (100)%
TN 5213 Concrete private residences construction - monolithic Payroll   (100)%
TN 5348 Tile, stone, mosaic or terrazzo work - inside Payroll   (100)%
TN 5474 Painting NOC Payroll   276%
TN 5645 Carpentry - detached dwellings Payroll   (48)%
TN 8742 Salespersons, collectors, messengers Payroll   143%
TN 8810 Clerical office employees Payroll   221%


Exit Interview conducted on: 08/31/2005 at 11:00:00 AM
Interviewee: Jane Doe Title: Bookkeeper


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

          Gross Sales for the period 06/01/2004 to 05/30/2005 is $4,330,582.

          

          Exposures vary based on available jobs for the insured versus use of insured and uninsured subs.

          In this insured’s line of work exposures will vary from year to year based on this availability of

          work and what is needed to be completed in each job.

          

          The insured provided payroll reports broken down by employee and class code which were used for the

          audit exposure. The only problem was that they had overtime, vacation, and holiday pay excluded

          from the payroll as one total for each employee. I informed the insured that vacation and holiday

          could not be deducted but premium O/T could. I requested that she forward me the O/T by itself for

          each employee so that this deduction could be made. This request was made on Thursday, 6/30. As

          of 7/8 I have not received this information. I am submitting the audit with no O/T deductions at

          this time.

          

          Extra time spent completing this audit due to the number of employees and subs. Payroll was

          verified and detailed off the even quarters and all insured subs had to have their COI’s verified.

          This took extra time based on the large number of employees and subs.

          

          Proper COI’s are maintained by the insured for their insured subs. Current COI’s are also backed

          up by COI’s from the prior years.

          

          A maximum of 50% was allowed for deduction of materials. Invoices were reviewed.