PREMIUM AUDIT
rev. 07/2019
AUDIT DISPUTE FORM
LWCC conducts periodic premium audits to identify changes in operations and to obtain all documentation
needed to ensure all policyholders are being charged accurate premiums.
If you do not agree with the findings on the audit, please complete this form and provide the necessary
documentation. To process your audit dispute, documentation is required. If your policy is currently pending
cancellation, completing this form does not stop your policy from cancelling; although, it will be given highest
priority.
Once you have completed, please send the form and documents to audits@lwcc.com. Additionally, we are
unable to accept audit disputes by phone.
We appreciate your cooperation with this process.
*Field is required.
*Policy period:
*Contact name:
*E-mail address:
*Policy number:
*Company name:
*Phone number:
*Reason(s) for the dispute:
DOCUMENTATION TO SUPPORT THE DISPUTE (SELECT ALL THAT APPLY):
Certificate of Insurance for workers’ compensation that relates to the audit period
941s
1099s
Profit and loss statement
General ledger
Copies of ALL checks written during policy period
Reclassification of an employee (include employee name, all job duties of employee and payroll)
Other:
PLEASE RETURN THIS COMPLETED FORM AND SUPPORTING DOCUMENTS TO AUDITS@LWCC.COM.
to
