CHSA Voluntary Audit Form

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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 ...

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Nombre de lectures	60
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AIG AIG Insurance Services, Inc. Premium Audit Divisionth 777 S. Figueroa Street, 14Flr Los Angeles, CA 90017 A Member Company of Phone : 661 -266-9089 American International Group, Inc Fax:: 661-266-9089 August 31, 2010 PolicyPeriod: Cancellation date: PolicyNumber: Carrier: American Home Assurance Telephone Audit NoticeNamed Insured: Policy Number:Reporting Period: CHECK THE APPROPRIATE LEGAL ENTITY OF YOUR BUSINESS: Corporate () LimitedLiability Company ( )Partnership () Individual( ) Other( ) Your Federal ID#:……………………………… PART I – LIST ALL EXECUTIVE OFFICERS/PARTNERS/OWNERS(stock percentage must be shown) Name TitleDescription ofTotal DateAppointedStock Duties RemunerationOwnership 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 DoubleShare of Descriptionof DutiesGross Payroll1 ½ xOT 2xWinning Purse Clerical Employees ALL OTHER EMPLOYEES Workers Comp.Gross OvertimeDouble Shareof Winning Code Descriptionof DutiesPayroll 1½ xOT 2xpurse PART III – DESCRIBE YOUR BUSINESS OPERATION IN DETAIL

PART IV – FREELANCE/CONTRACT/CASUAL/DAY LABOR—these could be Hot Walkers, Grooms, and/or Exercise Riders or others PAYMENTS TO FREELANCE / CASUAL / CONTRACT LABOR Type of work PerformedTotal Cost Paid Signature: Date: Name of contact:Daytime Phone Number:

AIG Insurance Services, Inc.Premium Audit Division INSTRUCTION FOR COMPLETING THE MAIL FORM READ ALL INSTRUCTIONS BEFORE ATTEMPTING TO COMPLETE THE MAIL FORM.IF ADDITIONAL SPACE IS NEEDED TO COMPLETE ANY PORTION OF THIS FORM, PLEASE ATTACH A SUPPLEMENT. THIS POLICY IS FOR WORK PERFORMED IN CALIFORNIA ONLY.INCLUDE ON THE REPORTING FORM ONLY THE PAYROLL, FREELANCE/CONTRACT/CASUAL LABOR IN CALIFORNIA. GROSS PAYROLLGross payroll is the monetary value at which service is recompensed.It includes gross wages; salaries; commissions; bonuses; vacation; holiday and sick pay; overtime payments, the market value of gifts, rental value of apartment or house if provided and all substitutes for money earned during the policy period by employees and officers and any other persons provided coverage under the policy. If Gross payroll includes: Shares of winning purses, employer provided perks (automobile, club membership, etc.), dismissal or severance pay, work uniform allowance.Please include in the gross payroll and show the amount included separately. PART I – EXECUTIVE OFFICERS/PARTNERS NOTE: executive officers of corporations are defined as the President, Vice President, Secretary, Treasurer, or any other officer appointed in accordance with the by-laws of the corporation. -List the full name, title and stock ownership of each executive officer or partner of your company. -Provide a description of their duties. PART II – EMPLOYEES -Show the gross payroll for employees in the spaces provided.Clerical are separated from all other employees. -Indicate overtime paid to employees in the appropriate columns. (a)Clerical Office Employees are defined as those employees whose duties areconfinedto keeping the books and records, conducting correspondence, or who are engaged wholly in general office work or office drafting, having no duty of any other nature in the service of the employer.Clerical employees must work exclusively in areas separated from all other work places of the employer.Employees who work part time as clerical employees but spend any portion of their time in any other duties cannot be assigned to clerical.Employee wages cannot be split between clerical and any other classification. Managers and supervisors of employees are assigned to the same classification as the employees they supervise and train, hire and fire.

PART III – DESCRIPTION OF OPERATION

Provide a full description of your operation/business. PART IV – FREELANCE LABOR - CONTRACT LABOR – CASUAL LABOR – DAY LABOR This section pertains to any work performed by individuals not on your normal payroll during the policy period.-Describe the service they performed.If the total cost paidIndicate what you paid to them for their service. to the freelance / casual/contract labor includes shares of winning purses.Do not include the shares of winning purses in reporting the total cost paid.