Carrier:
Test Insurance Company
111 Main Street
Any City, AL 35801
Agent:
Alpha Ins Agcy Inc
Policy Information:
GL 98-ZY-7654-3
General Liability
05/30/2014 to 05/30/2015
Audit ID: 184474
Audit Method: Physical
Audit Complete Type: Regular
Insured Name and Address:
XYZ Construction Inc
123 Any St
Nashville, TN 37208
Generated:
12/16/2015 3:22 PM
Completed By:
Keith West
WestK@wis-inc.com
Wilkinson Insurance Services
5650 Sanderson Street Suite Q
Huntsville, AL 35805
12/16/2015
Audrey: 4.1, PID: 52
Description Of Operations ... Audit 184474
Legal Entity: CORPORATIONPolicy No(s): GL 98-ZY-7654-3Policy Period: 05/30/2014 to 05/30/2015

XYZ Construction Inc is a doing business as a corporation in Nashville, TN.

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 98305 class code and all carpentry related work was placed under the 91340 class code.

Employees working in the offices of the insured have been placed excluded. These workers are performing various tasks such as receptionist, bookkeeping, scheduling, etc and are not exposed to the operations of the job site.

Several employees working as outside estimators have been excluded. They are performing job estimates and have travel responsibilities included within the regular scope of the job duties.

Overtime wages were paid and the premium portion has been deducted.

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 included in code 91583 per verification of their COI’s. Payments made to the insured subs were all covered within the COI dates. One uninsured sub was included in the appropriate class code per duties.

Officer 1 is the President and is included in code 91580. Officer 2 is the Secretary/Treasurer and is included in code 91580.   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 184474 ... 06/01/2014 to 06/01/2015 ... Policy GL 98-ZY-7654-3
Insured: XYZ Construction IncPolicy Period: 05/30/2014 to 05/30/2015
 Audit Period: 06/01/2014 to 06/01/2015
Policy No(s): GL 98-ZY-7654-3Auditor: Keith West

State Code Classification Loc Basis Mod Exposure
TN 91340 Carpentry-const.of resdntl.property not excdg.3 strs. Payroll 82,914
TN 91580 Contractors-exec. superv. or exec. superint. Payroll 52,000
TN 92338 Dry wall or wallboard installation Payroll 0
TN 94569 Floor covering installation Payroll 0
TN 98305 Painting-interior-buildings or structures Payroll 184,022
TN 98344 Paperhanging Payroll 0
TN 98678 Roofing - residential Payroll 0
Total Exposure: 318,936
Subcontractors Exposure Summary
TN 91340 Carpentry-Construction of Residential Property Not Exceeding 3 Stories Payroll 1,000
TN 91583 Contractors-Subcontracted Work-One or Two Family Dwellings Total Cost 1,812,528
Total Exposure: 1,813,528
Grand Total Exposure:2,132,464
Principal ... Audit 184474
 
Officer 1 President Included   P/R: 1.00
Start/End: 06/01/2014 to 06/01/2015 Min: 5,200 Max: 26,000  
  TN 91580 Contractors-exec. superv. or exec. superint.
Audit Period: 06/01/2014 to 06/01/2015 Total Amt: 94,000 Included At: 26,000  
Operations Manager / Executive Supervisor
 
Officer 2 S/T Included   P/R: 1.00
Start/End: 06/01/2014 to 06/01/2015 Min: 5,200 Max: 26,000  
  TN 91580 Contractors-exec. superv. or exec. superint.
Audit Period: 06/01/2014 to 06/01/2015 Total Amt: 52,200 Included At: 26,000  
Executive Supervisor
Exposure Recap ... Audit 184474 ... 06/01/2014 to 06/01/2015
State Code Classification / Name Loc Basis Mod Exposure
TN91340 Carpentry-const.of resdntl.property not excdg.3 strs. Payroll 
  Emp 13 Duties: Rough Carpentry 23,007
    Prem OT Credit @ 1.5 (1,430)
  Emp 14 Duties: Rough Carpentry 31,493
    Prem OT Credit @ 1.5 (778)
  Emp 15 Duties: Rough Carpentry 28,986
    Prem OT Credit @ 1.5 (262)
  Emp 16 Duties: Rough Carpentry 1,898
  ---------------
82,914
==========
TN91580 Contractors-exec. superv. or exec. superint. Payroll 
  *Officer 1 Duties: Operations Manager / Executive Supervisor 26,000
  *Officer 2 Duties: Executive Supervisor 26,000
  ---------------
52,000
==========
TN92338 Dry wall or wallboard installation Payroll 
  No Exposure   0
  ---------------
0
==========
TN94569 Floor covering installation Payroll 
  No Exposure   0
  ---------------
0
==========
TN98305 Painting-interior-buildings or structures Payroll 
  Emp 1 Duties: Painting - Interior 37,209
    Prem OT Credit @ 1.5 (115)
  Emp 10 Duties: Painting - Interior 5,685
    Prem OT Credit @ 1.5 (322)
  Emp 11 Duties: Painting - Interior 13,388
    Prem OT Credit @ 1.5 (78)
  Emp 12 Duties: Painting - Interior 8,190
  Emp 2 Duties: Painting - Interior 30,126
    Prem OT Credit @ 1.5 (1,885)
  Emp 3 Duties: Painting - Interior 32,730
    Prem OT Credit @ 1.5 (1,522)
  Emp 4 Duties: Painting - Interior 22,486
  Emp 5 Duties: Painting - Interior 360
  Emp 6 Duties: Painting - Interior 7,721
    Prem OT Credit @ 1.5 (8)
  Emp 7 Duties: Painting - Interior 5,175
    Prem OT Credit @ 1.5 (66)
  Emp 8 Duties: Painting - Interior 2,168
  Emp 9 Duties: Painting - Interior 22,858
    Prem OT Credit @ 1.5 (78)
  ---------------
184,022
==========
TN98344 Paperhanging Payroll 
  No Exposure   0
  ---------------
0
==========
TN98678 Roofing - residential Payroll 
  No Exposure   0
  ---------------
0
==========
TNEXCLUDED   Payroll 
  Emp 17 (Excluded) Duties: Receptionist 20,661
  Emp 18 (Excluded) Duties: Accounting 40,000
  Emp 19 (Excluded) Duties: Secretary 52,497
  Emp 20 (Excluded) Duties: Bookkeeping 37,625
  Emp 21 (Excluded) Duties: A/R 25,900
  Emp 22 (Excluded) Duties: Payroll 31,481
  Emp 23 (Excluded) Duties: Outside Estimator 191,352
  Emp 24 (Excluded) Duties: Outside Estimator 94,000
  Emp 25 (Excluded) Duties: Outside Estimator 73,539
  Emp 26 (Excluded) Duties: Outside Estimator 10,417
  ---------------
0
==========
Total Exposure: 318,936
Subcontractors Exposure Recap
TN91340Carpentry-Construction of Residential Property Not Exceeding 3 StoriesPayroll 
  Sub 2 - carpentry labor   1,000
 ---------------
1,000
==========
TN91583Contractors-Subcontracted Work-One or Two Family DwellingsTotal Cost 
  Insured Subs - 8   969,496
  Materials for Insd Subs   592,394
  Sub 1   36,906
  Sub 3   16,971
  Sub 4   14,686
  Sub 5   101,641
  Sub 6   3,445
  Sub 7   76,989
 ---------------
1,812,528
==========
Total Exposure: 1,813,528
Grand Total Exposure: 2,132,464
Worksheet3 ... Audit 184474
Name
Code Gross 6/1 - 6/1 Prem OT Credit @ 1.5
* Officer 1
91580 94,000 94,000  
* Officer 2
91580 52,200 52,200  
Emp 1
98305 37,209 37,209 (115)
Emp 2
98305 30,126 30,126 (1,885)
Emp 3
98305 32,730 32,730 (1,522)
Emp 4
98305 22,486 22,486  
Emp 5
98305 360 360  
Emp 6
98305 7,721 7,721 (8)
Emp 7
98305 5,175 5,175 (66)
Emp 8
98305 2,168 2,168  
Emp 9
98305 22,858 22,858 (78)
Emp 10
98305 5,685 5,685 (322)
Emp 11
98305 13,388 13,388 (78)
Emp 12
98305 8,190 8,190  
Emp 13
91340 23,007 23,007 (1,430)
Emp 14
91340 31,493 31,493 (778)
Emp 15
91340 28,986 28,986 (262)
Emp 16
91340 1,898 1,898  
Emp 17
EXCLUDED 20,661 20,661  
Emp 18
EXCLUDED 40,000 40,000  
Emp 19
EXCLUDED 52,497 52,497  
Emp 20
EXCLUDED 37,625 37,625  
Emp 21
EXCLUDED 25,900 25,900  
Emp 22
EXCLUDED 31,481 31,481  
Emp 23
EXCLUDED 191,352 191,352  
Emp 24
EXCLUDED 94,000 94,000  
Emp 25
EXCLUDED 73,539 73,539  
Emp 26
EXCLUDED 10,417 10,417  
No Exposure
92338
94569
98344
98678
0 0  
Totals:
  997,152 997,152 (6,544)
Adj:
  (6,544)    
Exposure:
  990,608    
Subcontractors ... Audit 184474
NameCertificate DetailExposure
Insured Subs - 8
Carrier: COI's verified Cost: 969,496
Policy Num: Materials: 0
Contract Period: 06/01/2014 to 06/01/2015 % Adjustments: 0
Limits: 1,000,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 969,496
Cost Detail
DateAmountNotes
234,423 Sub 8
32,676 Sub 9
89,765 Sub 10
12,387 Sub 11
54,356 Sub 12
9,876 Sub 13
533,667 Sub 14
2,346 Sub 15
Materials for Insd Subs
Carrier: Materials provided to insured subs Cost: 592,394
Policy Num: Materials: 0
Contract Period: 06/01/2014 to 06/01/2015 % Adjustments: 0
Limits: 600,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 592,394
Sub 1
Carrier: Granite State Cost: 36,906
Policy Num: GL8123467 Materials: 0
Policy Period: 06/26/2014 to 06/26/2015 % Adjustments: 0
Limits: 2,000,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 36,906
Sub 2 - carpentry labor
Carrier: Cost: 1,000
Policy Num: Materials: 0
Contract Period: 06/01/2014 to 06/01/2015 % Adjustments: 0
Limits:  
Audit State: TN
91340 Carpentry-Construction of Residential Property Not Exceeding 3 Stories 1,000
Sub 3
Carrier: Liberty Mutual Cost: 16,971
Policy Num: GL45655432 Materials: 0
Policy Period: 04/29/2014 to 04/29/2016 % Adjustments: 0
Limits: 5,000,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 16,971
Sub 4
Carrier: Builders Mutual Cost: 14,686
Policy Num: GL 45945ULD4 Materials: 0
Policy Period: 07/25/2013 to 07/25/2015 % Adjustments: 0
Limits: 2,000,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 14,686
Sub 5
Carrier: Bridgefield Casualty Cost: 101,641
Policy Num: GL56765453 Materials: 0
Policy Period: 09/01/2013 to 09/01/2015 % Adjustments: 0
Limits: 500,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 101,641
Sub 6
Carrier: Auto Owners Cost: 3,445
Policy Num: GL 4323432 Materials: 0
Policy Period: 07/22/2013 to 07/22/2016 % Adjustments: 0
Limits: 2,000,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 3,445
Sub 7
Carrier: AIG Cost: 76,989
Policy Num: GL 54645665 Materials: 0
Policy Period: 08/01/2013 to 08/01/2016 % Adjustments: 0
Limits: 2,000,000
Audit State: TN
91583 Contractors-Subcontracted Work-One or Two Family Dwellings 76,989
General Liability Workers ... Audit 184474 ... 06/01/2014 to 06/01/2015
State Code / Name Classification Loc Basis Mod Adj Exposure
TN 91340 Carpentry-const.of resdntl.property not excdg.3 strs. Payroll   82,914
  Emp 13 Prem OT Credit @ 1.5 1,430  
  Emp 14 Prem OT Credit @ 1.5 778  
  Emp 15 Prem OT Credit @ 1.5 262  
    Adjustments Total: 2,470  
TN 91580 Contractors-exec. superv. or exec. superint. Payroll   52,000
  *Officer 1 Over inclusion Max 68,000  
  *Officer 2 Over inclusion Max 26,200  
    Adjustments Total: 94,200  
TN 92338 Dry wall or wallboard installation Payroll   0
TN 94569 Floor covering installation Payroll   0
TN 98305 Painting-interior-buildings or structures Payroll   184,022
  Emp 1 Prem OT Credit @ 1.5 115  
  Emp 10 Prem OT Credit @ 1.5 322  
  Emp 11 Prem OT Credit @ 1.5 78  
  Emp 2 Prem OT Credit @ 1.5 1,885  
  Emp 3 Prem OT Credit @ 1.5 1,522  
  Emp 6 Prem OT Credit @ 1.5 8  
  Emp 7 Prem OT Credit @ 1.5 66  
  Emp 9 Prem OT Credit @ 1.5 78  
    Adjustments Total: 4,074  
TN 98344 Paperhanging Payroll   0
TN 98678 Roofing - residential Payroll   0
TN Excluded   Payroll 577,472  
Total Adjustments / Exposure: 678,216 318,936

Worksheet Gross Total Verification Source Total Audit Total
997,152 997,152 997,152
General Information ... Audit 184474
Insured: XYZ Construction Inc Phone: 615-123-4567
  123 Any St Fax:
  Nashville, TN 37208 Mobile:
  Contact: Emp 18 Email: Emp18@testISP.com
Records Obtained From: Emp 18
Phone: 615-123-4567
  123 Any St Fax:
  Nashville, TN 37208 Mobile:
    Email: Emp18@testISP.com
Verification Source Record
XYZ Construction Inc
Verification Source Record: 941, State, and Computer Reports
Employer's Federal ID No.: 12-3456789
1st Quarter 2015: 180,819
2nd Quarter 2015: 175,741
3rd Quarter 2014: 194,480
4th Quarter 2014: 435,367
Subtotal: 986,407
- Subtract 06/01/2015 to 06/30/2015 -57,295
+ Add 06/01/2014 to 06/30/2014 68,040
Adjusted Subtotal: 997,152
Total: 997,152
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 941 Returns examined? YES
Were U/C Returns 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 Was the profit & loss statement reviewed? YES
Notes ... Audit 184474 ... Policy GL 98-ZY-7654-3
Test Insurance Company
Any City, AL
XYZ Construction Inc Nashville, TN
Keith West Wilkinson Insurance Services Inc. (800) 356-7346 Ext 217

Percent difference between actual and estimated exposures (negative if est. > act.):
State Code Classification Prem Basis Location Est Act Pct Diff
TN 91340 Carpentry-const.of resdntl.property not excdg.3 strs. Payroll 265,000 0 (100.00)%
TN 91580 Contractors-exec. superv. or exec. superint. Payroll 52,000 0 (100.00)%
TN 92338 Dry wall or wallboard installation Payroll 122,000 0 (100.00)%
TN 94569 Floor covering installation Payroll 62,000 0 (100.00)%
TN 98305 Painting-interior-buildings or structures Payroll 156,000 0 (100.00)%
TN 98344 Paperhanging Payroll 40,000 0 (100.00)%
TN 98678 Roofing - residential Payroll 16,000 0 (100.00)%

Exit Interview conducted on 12/16/2015 at 10:57 AM
  Interviewee: Officer 1 Title: President  
  Records were
obtained from:
Title:  
 

Notes to Audit Department

Gross  revenue: $3,543,927.

Exposures varied based on availability of jobs and the nature of business the insured is in.  Exposures will fluctuate from year to year based on the types and scope of jobs obtained by the insured.

Billing time was included with the W/C file.

Signature Form ... Audit 184474
Insured: XYZ Construction Inc
Policy No(s): GL 98-ZY-7654-3 Policy Period: 05/30/2014 to 05/30/2015
 
The undersigned acknowledges that a representative of Wilkinson Insurance Services Inc. was present on the date below for the purpose of conducting an insurance audit for the policy indicated above.
 
Insured's Authorized Representative: Officer 1
Note: The signature is only viewable with Internet Explorer.
Signed: 12/16/2015 11:17:00 AM

A copy of this audit for the agent of record is approved.

Auditor: Wilkinson Insurance Services
5650 Sanderson Street Suite Q Huntsville, AL 35805
Progress ... Audit 184474
Test Insurance Company
Any City, AL
Insured: XYZ Construction Inc Nashville, TN
Policy No(s): GL 98-ZY-7654-3 Policy Period: 05/30/2014 to 05/30/2015
Auditor: Keith West Wilkinson Insurance Services Inc. (800) 356-7346 Ext 217
 
Progress Entry: 11/17/2008 at 07:59:28 PM
Entered By: Test Insurance Company
Remarks:
1st Audit Transmittals Marked Printed
Progress Entry: 02/19/2011 at 10:30:32 AM
Entered By: Rhonda Splear-Admin
Remarks:
1st Customer Satisfaction Surveys Marked Printed
Progress Entry: 04/27/2012 at 09:31:11 AM
Entered By: Test Insurance Company
Remarks:
1st Audit Transmittals Marked Printed