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
12/25/2014 to 12/25/2015
Audit ID: 184477
Audit Method: Physical
Audit Complete Type: Regular
Insured Name and Address:
XYC Service Station
123 Any St
Marion, MS 39342
Generated:
12/16/2015 3:25 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 184477
Legal Entity: INDIVIDUALPolicy No(s): HAZ II 1234-567Policy Period: 12/25/2014 to 12/25/2015

John Doe dba XYZ Service Station is operating as 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 deducted 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.

Exposure Summary ... Audit 184477 ... 01/01/2015 to 01/01/2016 ... Policy HAZ II 1234-567
Insured: XYC Service StationPolicy Period: 12/25/2014 to 12/25/2015
 Audit Period: 01/01/2015 to 01/01/2016
Policy No(s): HAZ II 1234-567Auditor: Keith West

State Code Classification Loc Basis Mod Exposure
MS HAZII Garage Liability 31,016
Total Exposure: 31,016
Principal ... Audit 184477
 
John Doe Owner Included   P/R: 1.00
Start/End: 01/01/2015 to 01/01/2016 Min: 5,200 Max: 5,200  
  MS HAZII Garage Liability
Audit Period: 01/01/2015 to 01/01/2016 Total Amt: 0 Included At: 5,200  
Store Manager
Exposure Recap ... Audit 184477 ... 01/01/2015 to 01/01/2016
State Code Classification / Name Loc Basis Mod Exposure
MSHAZII Garage Liability  
  Emp 1 Duties: Store worker 20,286
    Weekly Cap Adjustment; 52 Weeks (15,086)
  Emp 2 Duties: Garage worker 11,416
    Weekly Cap Adjustment; 52 Weeks (6,216)
  Emp 3 Duties: Garage worker 12,016
  Emp 4 Duties: Garage worker 5,123
    Weekly Cap Adjustment; 9 Weeks (4,223)
  Emp 5 Duties: Garage worker 5,959
    Weekly Cap Adjustment; 11 Weeks (4,859)
  Emp 6 Duties: Garage worker 370
    Weekly Cap Adjustment; 2 Weeks (170)
  Emp 7 Duties: Garage worker 336
    Weekly Cap Adjustment; 2 Weeks (136)
  Emp 8 Duties: Garage worker 4,157
    Weekly Cap Adjustment; 10 Weeks (3,157)
  *John Doe Duties: Store Manager 5,200
  ---------------
31,016
==========
Total Exposure: 31,016
Worksheet3 ... Audit 184477
Name
Code Gross YTD 2015 Adj
* John Doe
HAZII 0 0  
Emp 1
HAZII 20,286 20,286 (15,086)
Emp 2
HAZII 11,416 11,416 (6,216)
Emp 3
HAZII 12,016 12,016  
Emp 4
HAZII 5,123 5,123 (4,223)
Emp 5
HAZII 5,959 5,959 (4,859)
Emp 6
HAZII 370 370 (170)
Emp 7
HAZII 336 336 (136)
Emp 8
HAZII 4,157 4,157 (3,157)
Totals:
  59,663 59,663 (33,847)
Adj:
  (33,847)    
Exposure:
  25,816    
 
 
  Cell Details
  Emp 3 01/01/1900 0 Enter Number of Weeks >>
  04/08/2015 0 << Enter a Start Date
  08/28/2015 0 << Enter an End Date
  Emp 4 0 Enter Number of Weeks >>
  02/03/2015 0 << Enter a Start Date
  04/09/2015 0 << Enter an End Date
  Emp 5 0 Enter Number of Weeks >>
  10/11/2015 0 << Enter a Start Date
  01/01/2016 0 << Enter an End Date
  Emp 6 0 Enter Number of Weeks >>
  05/13/2015 0 << Enter a Start Date
  05/27/2015 0 << Enter an End Date
  Emp 7 0 Enter Number of Weeks >>
  06/28/2015 0 << Enter a Start Date
  07/12/2015 0 << Enter an End Date
  Emp 8 0 Enter Number of Weeks >>
  01/09/2015 0 << Enter a Start Date
  03/26/2015 0 << Enter an End Date
Hazard II Garage Liability Workers ... Audit 184477 ... 01/01/2015 to 01/01/2016
State Code / Name Classification Loc Basis Mod Adj Exposure
MS HAZII Garage Liability   31,016
  Emp 1 Weekly Cap Adjustment; 52 Weeks 15,086  
  Emp 2 Weekly Cap Adjustment; 52 Weeks 6,216  
  Emp 4 Weekly Cap Adjustment; 9 Weeks 4,223  
  Emp 5 Weekly Cap Adjustment; 11 Weeks 4,859  
  Emp 6 Weekly Cap Adjustment; 2 Weeks 170  
  Emp 7 Weekly Cap Adjustment; 2 Weeks 136  
  Emp 8 Weekly Cap Adjustment; 10 Weeks 3,157  
  *John Doe Under inclusion Min (5,200)  
    Adjustments Total: 28,647  
Total Adjustments / Exposure: 28,647 31,016

Worksheet Gross Total Verification Source Total Audit Total
59,663 59,663 59,663
General Information ... Audit 184477
Insured: XYC Service Station Phone: 601-555-5555
  123 Any St Fax:
  Marion, MS 39342 Mobile:
  Contact: John Doe Email:
Records Obtained From: John Doe
Phone: 601-555-5555
  123 Any St Fax:
  Marion, MS 39342 Mobile:
    Email:
Verification Source Record
XYC Service Station
Verification Source Record: 941, State, and Computer Reports
Employer's Federal ID No.: 12-3456789
1st Quarter 2015: 12,402
2nd Quarter 2015: 11,042
3rd Quarter 2015: 15,865
4th Quarter 2015: 16,458
Subtotal: 55,767
Sec 125 01/01/2015 to 01/01/2016 3,896
Adjusted Subtotal: 59,663
Total: 59,663
General Information Checklist
Are the records computerized? YES What is the condition of the records? FAIR
Were payroll journal records examined? YES Were general ledger records examined? NO 1
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? N/A
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? NO
Auto-Notes
1

The insured did not provide general ledger records as requested.

Notes ... Audit 184477 ... Policy HAZ II 1234-567
Test Insurance Company
Any City, AL
XYC Service Station Marion, MS
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
MS HAZII Garage Liability 20,800 31,016 49.12%

Exit Interview conducted on 12/16/2015 at 01:08 PM
  Interviewee: John Doe Title: Owner  
  Records were
obtained from:
Title:  
 

Notes to Audit Department

Exposure is higher due to more hires during the period.

 

Additional time was needed in order to verify start/end dates of employment for all workers.

Signature Form ... Audit 184477
Insured: XYC Service Station
Policy No(s): HAZ II 1234-567 Policy Period: 12/25/2014 to 12/25/2015
 
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: John Doe
Note: The signature is only viewable with Internet Explorer.
Signed: 12/16/2015 01:09:00 PM

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 184477
Test Insurance Company
Any City, AL
Insured: XYC Service Station Marion, MS
Policy No(s): HAZ II 1234-567 Policy Period: 12/25/2014 to 12/25/2015
Auditor: Keith West Wilkinson Insurance Services Inc. (800) 356-7346 Ext 217
 
Progress Entry: 02/19/2011 at 10:36:13 AM
Entered By: Rhonda Splear-Admin
Remarks:
1st Customer Satisfaction Surveys Marked Printed