CHSA Voluntary Audit Form

AIG Insurance Services, Inc. AIGPremium Audit Division th777 S. Figueroa Street, 14 Flr Los Angeles, CA 90017 Phone : 661 -266-9089 A Member Company of Fax: : 661-266-9089 American International Group, Inc August 31, 2010 Policy Period: Cancellation date: Policy Number: Carrier: American Home Assurance Telephone Audit Notice Named Insured: Policy Number: Reporting Period: CHECK THE APPROPRIATE LEGAL ENTITY OF YOUR BUSINESS: Corporate ( ) Limited Liability Company ( ) Partnership ( ) Individual ( ) Other ( ) Your Federal ID#:……………………………… PART I – LIST ALL EXECUTIVE OFFICERS/PARTNERS/OWNERS (stock percentage must be shown) Name Title Description of Total Date Appointed Stock Duties Remuneration Ownership Percentage PART II – EMPLOYEES ONLY – DO NOT INCLUDE OWNERS OR OFFICERS BELOW. OVERTIME, DOUBLE OVERTIME, SECTION 125 AND SHARES OF WINNING PURSES SHOULD BE INCLUDED IN THE GROSS PAYROLL AND SHOWN SEPARATELY IN THE SPACE PROVIDED. STANDARD EXCEPTION EMPLOYEES ONLY Overtime Double Share of Description of Duties Gross Payroll 1 ½ x OT 2x Winning Purse Clerical Employees ALL OTHER EMPLOYEES Workers Comp. Gross Overtime Double Share of Winning Code Description of Duties Payroll 1 ½ x OT 2x purse PART III – DESCRIBE YOUR BUSINESS OPERATION IN DETAIL PART IV – FREELANCE/CONTRACT/CASUAL/DAY LABOR—these ...