Toll-Free 844-472-0967
FAX 203-654-3613
Stamford, CT 06911-3247
biBERK
www.biBERK.com
PO Box 113247
Premium Audit for Your Workers' Compensation Policy
Agency:
Policy #: N9WC583785 Due Date: 05/18/2023
Policy Period: 05/03/2022 to 05/03/2023
biBERK
P.O. Box 113247
Stamford, CT 06911
Dear Policyholder:
The policy identified above will be expiring soon and according to the terms of all Workers' Compensation policies a
payroll audit must be performed to determine the actual cost of your coverage.
With your cooperation, we would like to simplify the process by gathering the necessary information by fax or mail.
Please complete ALL relevant sections of the enclosed Audit Form for the report period of your policy and fax the
document to us at 203-654-3613. The Audit Form may also be emailed to [email protected]. If you are
unable to fax, please mail the document to the address shown above. Failure to receive ALL required information will
necessitate a follow-up call and could cause delays in processing.
To get started, gather some key business information and documentation for your policy period, including:
Payroll records that list individual wages and job duties.
Federal Quarterly Tax Returns (IRS Form 941){1@cancel-tax1} (State Unemployment Quarterly Forms
are also acceptable).
If neither of those are available, Schedule C of the Federal Income Tax Return for Sole P r o p r i e t o r s ,
Form 1065 for LLC's/Partnerships, or Form 1120 for Corporations should be used.
All your Miscellaneous Income Forms (IRS Form 1099).
Any subcontractors’ Certificates of Insurance (ACORD Form 25).
Please understand that the law requires all Workers' Compensation policies be audited so you ultimately pay for
coverage based on actual, rather than estimated, payrolls. If we are unable to obtain this information, an estimated
audit with a substantial increase in premium will be generated.
If you have any general questions, please contact your agent. If you need assistance with our form, call us at
844-472-0967. We appreciate your anticipated cooperation.
Sincerely,
Premium Audit Department
Any person who makes, or causes to be made, any knowingly false or fraudulent material statement or representation with the
intent to defraud or deceive any insurance company regarding the proper calculation of premium, including (but not limited to) the
amount of payroll or employee job duties or other facts relevant to the proper classification of payroll, commits a fraudulent
insurance act, which is a crime and may subject such person to criminal or civil penalties.
Date Prepared: 04/19/2023
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