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Contact Name:
Title:
Company Name:
Address:
Address (Cont):
City:
County:
Zip Code:
State:
Phone #:
Cell #:
Fax #:
Email:
WC Annual Premium:
WC Insurance Company:
WC Insurance Co. Phone:
WC Insurance Co. Fax:
Workers' Comp Policy #:
GL Annual Premium:
GL Insurance Company:
GL Insurance Co. Phone:
GL Insurance Co. Fax:
General Liability Policy #:
Agent/Agency Name:
Agent Phone:
Agent Fax:
# of Employees:
Audit Consultant:
Contact Preference:
Comments:

Audit Application 

To apply for your audit, please complete the form below.
All information provided is held in the strictest of confidence.

It is important that all information requested be provided in order
for us to complete our task as thoroughly and quickly as possible.
Upon receipt of this application, you will be contacted to confirm
your information. A client agreement and letter of authority will
be forwarded to you for review and authorization to proceed.
Please sign and fax it in as soon as possible. Any delay simply
delays your refund from coming to you in a timely fashion.
Thank you!