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
05/30/2014 to 05/30/2015
Audit ID: 184473
Audit Method: Physical
Audit Complete Type: Regular
Insured Name and Address:
XYZ Construction Inc
123 Any St
Nashville, TN 37208
Generated:
12/16/2015 3:13 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 184473
Legal Entity: CORPORATIONPolicy No(s): WC 12-AB-1234-1Policy 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 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 and are not exposed to the operations of the job site.

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.

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

No bonuses were paid in this period to included employees.  The only bonuses were for excluded officers.

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 exemption filed on the TN registry. Officer 2 is the Secretary/Treasurer and is excluded per exemption filed on the TN registry.   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 ... 06/01/2014 to 06/01/2015 ... Policy WC 12-AB-1234-1
Insured: XYZ Construction IncPolicy Period: 05/30/2014 to 05/30/2015
 Audit Period: 06/01/2014 to 06/01/2015
Policy No(s): WC 12-AB-1234-1Auditor: Keith West

State Code Classification Loc Basis Mod 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 5462 Glazier - away from shop Payroll 0
TN 5474 Painting NOC Payroll 184,022
TN 5645 Carpentry - detached dwellings Payroll 82,914
TN 8742 Salespersons, collectors, messengers Payroll 369,308
TN 8810 Clerical office employees Payroll 208,164
Total Exposure: 844,408
Subcontractors Exposure Summary
TN 5462 Glazier - Away From Shop & Drivers Payroll 3,445
TN 5645 Carpentry - Detached One or Two Family Dwellings Payroll 1,000
Total Exposure: 4,445
Grand Total Exposure:848,853
Principal ... Audit 184473
 
Officer 1 President Excluded   P/R: 0.00
Start/End: 06/01/2004 to 06/01/2005 Min: 41,600 Max: 166,400  
  TN
Audit Period: 06/01/2004 to 06/01/2005 Total Amt: 94,000  
Operations Manager / Executive Supervisor
 
Officer 2 S/T Excluded   P/R: 0.00
Start/End: 06/01/2004 to 06/01/2005 Min: 41,600 Max: 166,400  
  TN
Audit Period: 06/01/2004 to 06/01/2005 Total Amt: 52,200  
Executive Supervisor
Exposure Recap ... Audit 184473 ... 06/01/2014 to 06/01/2015
State Code Classification / Name Loc Basis Mod Exposure
TN0042 Landscape gardening Payroll 
  No Exposure   0
  ---------------
0
==========
TN5213 Concrete private residences construction - monolithic Payroll 
  No Exposure   0
  ---------------
0
==========
TN5348 Tile, stone, mosaic or terrazzo work - inside Payroll 
  No Exposure   0
  ---------------
0
==========
TN5462 Glazier - away from shop Payroll 
  No Exposure   0
  ---------------
0
==========
TN5474 Painting NOC 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
==========
TN5645 Carpentry - detached dwellings 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
==========
TN8742 Salespersons, collectors, messengers Payroll 
  Emp 23 Duties: Outside Estimator 191,352
  Emp 24 Duties: Outside Estimator 94,000
  Emp 25 Duties: Outside Estimator 73,539
  Emp 26 Duties: Outside Estimator 10,417
  ---------------
369,308
==========
TN8810 Clerical office employees Payroll 
  Emp 17 Duties: Receptionist 20,661
  Emp 18 Duties: Accounting 40,000
  Emp 19 Duties: Secretary 52,497
  Emp 20 Duties: Bookkeeping 37,625
  Emp 21 Duties: A/R 25,900
  Emp 22 Duties: Payroll 31,481
  ---------------
208,164
==========
TNEXCLUDED    
  *Officer 1 (Excluded) Duties: Operations Manager / Executive Supervisor 94,000
  *Officer 2 (Excluded) Duties: Executive Supervisor 52,200
  ---------------
0
==========
Total Exposure: 844,408
Subcontractors Exposure Recap
TN5462Glazier - Away From Shop & DriversPayroll 
  Sub 6 - glazier work   3,445
 ---------------
3,445
==========
TN5645Carpentry - Detached One or Two Family DwellingsPayroll 
  Sub 2 - carpentry labor   1,000
 ---------------
1,000
==========
Total Exposure: 4,445
Grand Total Exposure: 848,853
Worksheet3 ... Audit 184473
Name
Code Gross 6/1 - 6/1 Prem OT Credit @ 1.5
* Officer 1
EXCLUDED 94,000 94,000  
* Officer 2
EXCLUDED 52,200 52,200  
Emp 1
5474 37,209 37,209 (115)
Emp 2
5474 30,126 30,126 (1,885)
Emp 3
5474 32,730 32,730 (1,522)
Emp 4
5474 22,486 22,486  
Emp 5
5474 360 360  
Emp 6
5474 7,721 7,721 (8)
Emp 7
5474 5,175 5,175 (66)
Emp 8
5474 2,168 2,168  
Emp 9
5474 22,858 22,858 (78)
Emp 10
5474 5,685 5,685 (322)
Emp 11
5474 13,388 13,388 (78)
Emp 12
5474 8,190 8,190  
Emp 13
5645 23,007 23,007 (1,430)
Emp 14
5645 31,493 31,493 (778)
Emp 15
5645 28,986 28,986 (262)
Emp 16
5645 1,898 1,898  
Emp 17
8810 20,661 20,661  
Emp 18
8810 40,000 40,000  
Emp 19
8810 52,497 52,497  
Emp 20
8810 37,625 37,625  
Emp 21
8810 25,900 25,900  
Emp 22
8810 31,481 31,481  
Emp 23
8742 191,352 191,352  
Emp 24
8742 94,000 94,000  
Emp 25
8742 73,539 73,539  
Emp 26
8742 10,417 10,417  
No Exposure
0042
5213
5348
5462
0 0  
Totals:
  997,152 997,152 (6,544)
Adj:
  (6,544)    
Exposure:
  990,608    
Subcontractors ... Audit 184473
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:  
Audit State: TN
(No code) 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:  
Audit State: TN
(No code) 592,394
Sub 1
Carrier: Granite State Cost: 36,906
Policy Num: WC8123467 Materials: 0
Policy Period: 06/26/2014 to 06/26/2015 % Adjustments: 0
Limits:  
Audit State: TN
(No code) 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
5645 Carpentry - Detached One or Two Family Dwellings 1,000
Sub 3
Carrier: Liberty Mutual Cost: 16,971
Policy Num: WC45655432 Materials: 0
Policy Period: 04/29/2014 to 04/29/2016 % Adjustments: 0
Limits:  
Audit State: TN
(No code) 16,971
Sub 4
Carrier: Builders Mutual Cost: 14,686
Policy Num: WC 45945ULD4 Materials: 0
Policy Period: 07/25/2013 to 07/25/2015 % Adjustments: 0
Limits:  
Audit State: TN
(No code) 14,686
Sub 5
Carrier: Bridgefield Casualty Cost: 101,641
Policy Num: WC56765453 Materials: 0
Policy Period: 09/01/2013 to 09/01/2015 % Adjustments: 0
Limits:  
Audit State: TN
(No code) 101,641
Sub 6 - glazier work
Carrier: Cost: 3,445
Policy Num: Materials: 0
Contract Period: 06/01/2014 to 06/01/2015 % Adjustments: 0
Limits:  
Audit State: TN
5462 Glazier - Away From Shop & Drivers 3,445
Sub 7
Carrier: AIG Cost: 76,989
Policy Num: WC 54645665 Materials: 0
Policy Period: 08/01/2013 to 08/01/2016 % Adjustments: 0
Limits:  
Audit State: TN
(No code) 76,989
Workers' Compensation Workers ... Audit 184473 ... 06/01/2014 to 06/01/2015
State Code / Name Classification Loc Basis Mod Adj 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 5462 Glazier - away from shop Payroll   0
TN 5474 Painting NOC 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 5645 Carpentry - detached dwellings 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 8742 Salespersons, collectors, messengers Payroll   369,308
TN 8810 Clerical office employees Payroll   208,164
TN Excluded   146,200  
Total Adjustments / Exposure: 152,744 844,408

Worksheet Gross Total Verification Source Total Audit Total
997,152 997,152 997,152
General Information ... Audit 184473
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
Workers' Compensation Checklist
15 day rule observed for the audit period? YES Is the legal entity correct? YES
Are there any additional entities? NO Are there any new operations? NO
Were there leased employees? NO If employees lumped, did you provide # of employees? N/A
Were non-guaranteed bonuses excluded? N/A Were employee contributions to benefit plans included? N/A
Were commissions included? N/A Were housing allowances included? N/A
Were tips excluded? N/A Were subcontractors used? YES
Invoices reviewed for materials credit for uninsured subs? NO Were contract drivers used? NO
Was premium overtime deducted? YES Does the insured operate an aircraft? NO
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 184473 ... Policy WC 12-AB-1234-1
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 0042 Landscape gardening Payroll 3,126 0 (100.00)%
TN 5213 Concrete private residences construction - monolithic Payroll 5,115 0 (100.00)%
TN 5348 Tile, stone, mosaic or terrazzo work - inside Payroll 15,399 0 (100.00)%
TN 5474 Painting NOC Payroll 50,000 0 (100.00)%
TN 5645 Carpentry - detached dwellings Payroll 165,000 0 (100.00)%
TN 8742 Salespersons, collectors, messengers Payroll 152,165 0 (100.00)%
TN 8810 Clerical office employees Payroll 64,879 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.

Additional time was spent verifying employee wages, separating exposure by class code, verifying sub payments and COI's and general write-up of the file.

Signature Form ... Audit 184473
Insured: XYZ Construction Inc
Policy No(s): WC 12-AB-1234-1 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 10:58:00 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 184473
Test Insurance Company
Any City, AL
Insured: XYZ Construction Inc Nashville, TN
Policy No(s): WC 12-AB-1234-1 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