The audit form will take approximately 20 minutes to complete.

Please note that once you start the form there is no option to save and complete later. If you need to go back to a prior page, do not use the back arrow in the browser, instead click the PREVIOUS button.

Section 1 – Insured/Policy Information

Insured name, as listed on the policy

Insured email

Policy number

Policy/audit period

Start date

End date

FEIN#

Type of entity

If other, explain

Insured website

Page 1 of 8

Section 2 - Employee wages during the audit period

Total gross employee payroll ($) :

- Include vacation pay, overtime, tips, bonuses, and commission

- Exclude officer payroll

Total overtime pay, if applicable.

Time and a half ($):

Double time ($):

Total tips (if applicable) amount of tips received by employees:

Employee payroll and job duties

Please list all employees and their duties. If you utilize an accounting software or payroll service, please upload a summarized report that includes all duties for each employee employed during the audit period. If you have less than 10 employees or do not have access to a summarized payroll report, please enter the information manually below. Manual entry is limited to 10 employees.

In the event that you have greater than 10 employees please prepare a summary of employee’s wages by duties.

Enter manually (manual entry is limited to 10 employees)

File 1 Choose file

File 2 Choose file

File 3 Choose file

File 4 Choose file

Name 1

Job duties 1

Total gross wages ($)

Gross OT 1 ($)

Tips 1($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance (if applicable) 1

Name 2

Job duties 2

Total gross wages 2 ($)

Gross OT 2 ($)

Tips 2 ($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance (if applicable) 2 ($)

Name 3

Job duties 3

Total gross wages 3 ($)

Gross OT 3 ($)

Tips 3 ($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance (if applicable) 3 ($)

Name 4

Job duties 4

Total gross wages 4 ($)

Gross OT 4 ($)

Tips 4 ($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance (if applicable) 4

Add additional employees

Name 5

Job duties 5

Total gross wages 5 ($)

Gross OT 5 ($)

Tips 5 ($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance 5 ($)

Name 6

Job duties 6

Total gross wages 6 ($)

Gross OT 6 ($)

Tips 6 ($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance (if applicable) 6 ($):

Name 7

Job duties 7

Total gross wages 7 ($)

Gross OT 7 ($)

Tips 7 ($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance (if applicable) 7 ($)

Name 8

Job duties 8

Total gross wages 8 ($)

Gross OT 8 ($)

Tips 8 ($)

Hourly wage rate, if a contractor working in CA ($)

Housing allowance 8 ($)

Name 9

Job duties 9

Total gross wages 9 ($)

Gross OT 9 ($)

Tips 9 ($)

Hourly wage rate, if a contractor working in CA

Housing allowance (if applicable) 9 ($)

Name 10

Job duties 10

Total gross wages 10 ($)

Gross OT 10 ($)

Tips 10 ($)

Hourly wage rate, if a contractor working in CA 10 ($)

Housing allowance 10 ($)

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Section 3 - Payroll verification requirements

The premium for the audit policy term will determine if quarterly documents are required. Examples are: Federal 941 Quarterly Forms and/or State Unemployment Quarterly Forms.

Using the chart below, please locate the state where the majority or all the business is conducted. Was the premium greater than the premium threshold listed for the state below? Yes the premium was greater No the premium was less

States	Premium threshold
AK	$3,000
CA	$8,000
DE, MA, NY, PA	$2,000
All other states	$5,000

Please upload your quarterlies during your expiring policy term.

It is encouraged to attach the quarterly forms now, as they may be requested by the auditor at the time of processing.

Quarter 1 Choose file

Quarter 2 Choose file

Quarter 3 Choose file

Quarter 4 Choose file

Additional file 1 Choose file

Additional file 2 Choose file

Additional file 3 Choose file

Additional file 4 Choose file

Page 3 of 8

Section 5 - Principals/Ownership

Have there been any changes to the entry type or the principal/ownership? Yes No

Please provide details of the changes and the date it occurred. Make sure to include applicable dates, name, title, percentage of ownership, job duties and gross compensation/draws/distributions.

Provide information about owners, principals, officers, LLC members, partners and proprietors.

Name 1

Title 1

Percent ownership 1

Job duties 1

Gross compensation/draws/distribution 1 ($)

Name 2

Title 2

Percent ownership 2

Job duties 2

Gross compensation/draws/distribution 2 ($)

Name 3

Title 3

Percent ownership 3

Job duties 3

Gross compensation/draws/distribution 3 ($)

Name 4

Title 4

Percent ownership 4

Job duties 4

Gross compensation/draws/distribution 4 ($)

Name 5

Title 5

Percent ownership 5

Job duties 5

Gross compensation/draws/distribution 5 ($)

If more than 5 principals/owners, attach a summary including names, titles, percentage of ownership, job duties and gross compensation/draws/distributions.

Choose file

Page 5 of 8

Section 7 - Additional questions

Please indicate if you permit Markel to release the audit worksheets and audit information including payroll documentation to your agent or broker. Yes No

Do you have any of the following exposures? Yes No

If yes, please explain:

- Asbestos removal

- Chemical manufacturing

- Wrecking or demolition

- Firefighters and police officers

- Off-shore or subaqueous work

- Railroad operation or construction

- Flammable liquids or flammable gases

- Aircraft flight or ground operations of any kind

- Sewer, subway, or water main construction, shaft sinking, or tunneling

- Underground mining, strip mining, or quarrying

- Caisson or coffer dam work; dam, dike, lock, or revetment construction

- Nuclear, radioactive, chemical, or biological contamination.

- Amusement parks or devices, exhibitions (including fireworks), carnivals or circuses, sports events and/or participants

- Maritime or federal employments; marine work of any kind, operation of drydocks, any U.S. Longshoremen's and Harbor Worker's exposures

- Explosives, substances intended for use as an explosive, ammunitions, fuses, arms, magnesium, propellant charges, detonating devices, fireworks, nitroglycerine, celluloid, or pyroxylin

- Gas companies, dealers, or distributors, except those in the gasoline service station business; oil or gas operators, lease operators or contractors; oil or gas well works; oil or gas pipeline construction or operations; oil rig and derrick work; onshore or offshore gas or oil drilling

Page 7 of 8

Section 8 - Audit contact information

Please complete this section with your information. Markel will send a copy of this online form to the insured’s email entered in Section 1, as well as your email listed below.

Name:

Title:

Phone:

By clicking submit below, I certify that I am an authorized representative of the insured for the purpose of this workers compensation audit. I also certify that all information provided is complete and accurate, and understand that the email provided will receive a copy of this audit documentation.

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Have questions?

Speak with a Markel Specialty representative.

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Chat online Monday - Friday, 7:00 a.m. - 7:00 p.m. CST.

The audit form will take approximately 20 minutes to complete.

Section 1 – Insured/Policy Information

Page 1 of 8

Section 2 - Employee wages during the audit period

Employee payroll and job duties

In the event that you have greater than 10 employees please prepare a summary of employee’s wages by duties.

Page 2 of 8

Section 3 - Payroll verification requirements

Page 3 of 8

Section 4 - Operations

Page 4 of 8

Section 5 - Principals/Ownership

Provide information about owners, principals, officers, LLC members, partners and proprietors.

Page 5 of 8

Section 6 - Subcontractors, contract labor, 1099 and any other non-W2 labor

If more than 9 contractors or subcontractors were utilized, attach a summary. Include amount paid, type of work performed, dates of service, labor/materials costs if applicable, and their policy number and period. Please also attach any certificates of insurance.

If more than three contractors or subcontractors were utilized, please upload a spreadsheet of the requested detail.

Page 6 of 8

Section 7 - Additional questions

Page 7 of 8

Section 8 - Audit contact information

Page 8 of 8

Have questions?