Workers compensation or payroll based general liability phr form

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Hartford, ct 06104-2927. insured name: address 1: address 2: city: state:______ zip:______. policy number: (i.e. xxxx-1a234567). policy term: (800) 879-0892.

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POLICYHOLDERAUDITREPORTFAXCustomerService1.TELLUSABOUTYOURBUSINESSPleaseprovideadetaileddescriptionofyourbusinessoperations(e.g.workperformed;productmanufactured;servicesprovided)includinganynewoperationsaddedduringthisterm.2.TELLUSABOUTYOURCOMPANYSTRUCTURE(CircleOne)IndividualPartnershipCorporationLimitedLiabilityCo.ListSoleProprietor,Partner(s),orCorporateOfficer(s)alongwiththeirduties,numberofweeksemployedduringthepolicyterm,andtheirearnings/draws/profits.Includeallprincipalseveniftheyreceivenopayorhaveelected,byfilinganexclusionform,nottobecovered.Pleasegivemoredetailthansimply"administrative"or"managerial"duties.Company#ofWeeksActualEmployedEarningsNameUseOnlySpecificDutiesTitleCLPAPHRAPremium AuditP.O. Box 2927Hartford, CT 06104-2927Insured Name: ____________________________________________Address 1: _______________________________________________Address 2: _______________________________________________City: ________________________ State:________ Zip:___________Policy Number: (...

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