Premium Audit Review Request
Name of Insured
Name of Insured - as it appears on your policy
Policy Number
Enter Policy Number. If there are multiple Policy Numbers enter all, separated by commas.
Policy Period
Line of Business
General Liability
Workers Comp
BOP
Commercial Auto
Commercial Property
Umbrella
Crime
Inland Marine
E&O
COP
ALL
Cyber
Select General Liability, Workers Comp or Both
Contact Name
Contact email
Contact Phone Number
Valid Dispute Reason
Audit totals
Incorrect classification
Other
Gross totals do not match records
Allowable adjustments not made
Contract/subcontract labor improperly included
Providing actual figures to replace estimated audits (non-productive)
Business operations inaccurately classified/described
Individual employees inaccurately classified/described
Dispute Details
Notes
Provide specific details regarding the audit discrepancy noted above
Attachment
Attach source documents supporting revision. To submit multiple documents, hold down Ctrl key while selecting more than one document.
Are your requesting a bill hold?
Yes
No
Summary
(required)