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Workers Comp Audit Worksheet

Workers Comp Audit Worksheet Template for United States

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Key Requirements PROMPT example:

Workers Comp Audit Worksheet

"Need to create a Workers Comp Audit Worksheet for our manufacturing company operating in three states (CA, TX, NY), with special attention to our recent expansion of operations and addition of 50 new employees in January 2025."

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Document background
The Workers Comp Audit Worksheet is a critical document used in the United States insurance industry to ensure accurate premium calculations for workers' compensation coverage. This document is typically required annually and becomes necessary when actual payroll figures need to be reconciled with estimated amounts used for initial premium calculations. The worksheet helps determine if additional premiums are due or if refunds are warranted based on actual versus estimated exposure. It includes detailed information about employee classifications, payroll records, subcontractor usage, and various risk factors that affect premium calculations.
Suggested Sections

1. Business Information: Legal business name, FEIN, policy number, audit period details

2. Payroll Records: Detailed breakdown of payroll by classification code and verification documentation

3. Employee Classification: List of job titles and corresponding workers' compensation class codes with descriptions

4. Subcontractor Information: Details of any subcontractors used during the policy period including contract values

Optional Sections

1. Officer Exclusions: Documentation and details of corporate officers who have elected to be excluded from coverage

2. Multiple States Operations: Breakdown of operations by state with state-specific classification requirements

Suggested Schedules

1. Schedule A - Payroll Summary: Detailed monthly breakdown of payroll by classification code and employee type

2. Schedule B - Certificates of Insurance: Copies of valid insurance certificates for all subcontractors used during the policy period

3. Schedule C - Experience Modification Worksheet: Calculation and documentation of experience modification factor based on claims history

4. Appendix A - State-Specific Forms: Required state-specific forms and supplemental documentation for workers' compensation audit

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓƵ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Clauses




















Industries

OSHA: Occupational Safety and Health Act - Federal legislation that sets and enforces protective workplace safety and health standards

FLSA: Fair Labor Standards Act - Federal law establishing minimum wage, overtime pay, recordkeeping, and youth employment standards

ADA: Americans with Disabilities Act - Federal law prohibiting discrimination against individuals with disabilities, including workplace accommodations

State Workers' Compensation Laws: Individual state legislation governing workers' compensation requirements, benefits, and procedures specific to each jurisdiction

NCCI Guidelines: National Council on Compensation Insurance standards including classification codes, experience modification factors, and premium calculation rules

State Workers' Compensation Board Regulations: Regulatory requirements set by state boards governing claims processing, reporting, and compliance procedures

Insurance Commissioner Requirements: State-specific insurance regulations and compliance requirements for workers' compensation coverage

Payroll Record Requirements: Mandatory documentation of employee wages, hours, classifications, and other payroll information for audit purposes

HIPAA: Health Insurance Portability and Accountability Act - Federal law protecting confidentiality and security of medical information

State Privacy Laws: State-specific legislation governing the protection and handling of employee personal and medical information

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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