Workers' Compensation Audit Information Checklist

Workers' Compensation Audit Information Checklist
Please complete this checklist to provide all necessary information and documents for your workers' compensation audit.
Business/Organization Name
Contact Person Full Name
First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Workers' Compensation Policy Number
Audit Period (Start Date)
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Audit Period (End Date)
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Payroll Information: Please upload payroll records for the audit period (e.g., payroll summaries, tax forms).
Cancelof
List of Employees and Job Classifications (attach document or enter below)
Did you use any subcontractors or independent contractors during the audit period?
If yes, please upload certificates of insurance for all subcontractors/independent contractors.
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Have there been any workers' compensation claims or incidents during the audit period?
If yes, please provide a summary of claims or upload loss runs/claim reports.
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Have there been any changes in business operations, locations, or employee roles during the audit period?
If yes, please describe the changes below.
Should be Empty: