Premium Audit Revision Request

Complete this form for consideration of an audit revision.

If you do not agree with the audit, identify the basis of the review and provide the necessary documentation to support the revision within 30 days of the final audit summary date. While the request is under review, you must continue to submit payments.

Instructions

If you do not agree with the audit, identify the basis of the review and provide the necessary documentation to support the revision within 30 days of the final audit summary date. While the request is under review, you must continue to submit payments.

Supporting Documentation

Please upload documentation to support your revision request. Documentation may include:

Employee Classification
- Employees’ name(s)
- Job titles
- Detailed description of job functions

Uninsured Subcontractors or Contract Labor
- Name of subcontractor/contractor
- Written contracts in place
- Detailed description of work completed
- Certificate of Workers' Compensation Insurance

Payroll
- Payroll documentation
Click or drag files to this area to upload. You can upload up to 20 files.
Allowable file types: .csv, .doc, .heic, .pdf, .png, .jpg, and .xls