Replacement Self-Audit Forms for Premium Audit
In the event the pre-addressed policy
specific form we sent you has been lost or misplaced, you may
download and print off one of the blank forms below as a
replacement.
Underwriting Forms & Applications
In
order to view and print these forms you
must have a version of Adobe Acrobat
Reader® installed on your computer. The
latest version of Adobe Acrobat Reader®
is free and can be downloaded and
installed from the following address:
http://www.adobe.com/products/acrobat/readstep.html
| Workers' Compensation Self-Audit
Form |
Download Type |
| This is a
blank self-audit payroll form for
Workers' Compensation policies. |
399 KB
|
| General Liability Self-Audit
Form |
|
|
This is a blank self-audit form
for General Liability policies. This
can be used for any classifications
where the premium basis is one of
the following: payroll, sales
(receipts), gallonage or cost (total
payments to subcontractors). If you
have other types of classifications
based on area of square footage
which do not routinely change, there
is no need to report these items.
These later items are not typically
subject to audit or adjustment.
|
490 KB
|
| Garage Liability Self-Audit Form
|
|
| This is a
blank payroll self-audit form for
garage/service stations, rated on
payroll. |
401 KB
|
|
Auto Dealer Inventory Reporting
Form
|
|
| This is a
blank monthly (or quarterly)
inventory report for Franchised Auto
Dealers' physical damage coverage.
|
323 KB
|
Fill the information
in exactly as it is shown on your policy and
sign the document. You may then return a
copy of the completed form by sending it to
the address or fax number shown below.
Utica National Insurance Group
Attn: Home Office Premium Audit
P.O. Box 530
Utica, NY 13503
FAX: 315-266-4043