Copper Questions

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information:

• Company Legal Name:

• Address:

• City:

• State:

• Zip:

• Key Contact:

• Phone:

• Fax:

• Email:

• Website:

• FEIN:

• Year Business Began:

• Brief Description of Organization:

• # of full time employees:

• # of part time employees:

• FUTA Exempt?

  Yes

  No

  N/A

• Structure:

  Select S Corp C Corp LLC Partnership Non-Profit 501c3

  • S Corp
  • C Corp
  • LLC
  • Partnership
  • Non-Profit
  • 501c3

• # of Locations:

• States:

• Owner Name: Title: % Ownership

• For Health Insurance Underwriting Only: I give Merit's Broker, LMC, and Merit permission to contact any employee regarding any outstanding health information.

• Signature:

  Sign

Employee Benefits:

Medical:

• Administration Fees COBRA:

• Administration Fees Annual 5500

• Administration Fees Other:

Retirement Planning:

• Type of Plan:

  401 (k)

  403 (b)

  Other

• Current Plan Assets (if known): $

• Annual Plan Testing Fees:

• Annual Administration Feed:

• Annual Audit Fees:

• Annual 5500 Fees:

• Fiduciary Liability Insurance Cost:

Ancillary Benefits:

• Dental:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• Vision:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• Short Term Disability:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• Long Term Disability:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• Flexible Spending Account:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• Administration Costs: Section 125 Maintenance:

• Life:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• EAP:

  Select Yes No

  • Yes
  • No

• Annual Cost:

• Wellness:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• Annual Costs:

• Other Pre-tax Benefits:

  Select Yes No Company Paid

  • Yes
  • No
  • Company Paid

• if so, what?

• Any additional benefits requested by employees?

Benefits Staff:

• Number of Employees:

• Average pay rate:

• Number of Hours Spent per Week:

• Briefly describe the primary duties of these employee(s);

Human Resources:

• Do you have Employment Practices Insurance (EPLI)?

  Yes

  No

  N/A

• Annual Premium:

• Deductible:

• Plan limits:

• Do you conduct Pre-employment background checking?

  Yes

  No

  N/A

• Types of checks conducted:

  Select Local State Federal

  • Local
  • State
  • Federal

• Costs per check:

• Do you conduct drug testing?

  Yes

  No

  N/A

• Pre-employment?

  Yes

  No

  N/A

• Post accident?

  Yes

  No

  N/A

• Random?

  Yes

  No

  N/A

• Reasonable suspicion?

  Yes

  No

  N/A

• Cost per Drug Screen?

• Do you utilize Pre-employment job match testing?

  Yes

  No

  N/A

• Vendor:

• Cost per test:

• Do you run classified ads for open positions?

  Yes

  No

  N/A

• Sources used:

• Cost per Ad:

• What is your three year turnover %?

• How often do you update your employee handbook?

• Do you conduct employee engagement surveys?

  Yes

  No

  N/A

• What is your unemployment success rate?

• How much do you typically spend on non-EPLI claim employment legal fees annually?

Human Resource Staff:

• Number of Employees:

• Average pay rate:

• Number of Hours Spent per Week:

• Briefly Describe the Primary Duties of These Employees:

Payroll and Payroll Taxes:

• How are you processing payroll?

  Select In-house Outsourced

  • In-house
  • Outsourced

• Vendor:

• Payroll processing fee:

• Report fee:

• W-2 processing fee:

• Tax returns:

• Garnishments:

• Additional fees:

• Payroll Frequency:

  Select Weekly Bi-Weekly Semi-Monthly Monthly

  • Weekly
  • Bi-Weekly
  • Semi-Monthly
  • Monthly

• Do you utilize a time and attendance system?

  Yes

  No

  N/A

• Do you own or lease?

  Select Own Lease

  • Own
  • Lease

• Vendor:

• Cost:

• Do you have a HRIS system?

  Yes

  No

  N/A

• Do you own or lease?

  Select Own Lease

  • Own
  • Lease

• Vendor:

• Cost:

Payroll and Payroll Tax Staff:

• Number of Staff:

• Average pay rate:

• Number of Hours Spent Per Week:

• Briefly describe the primary duties do these employee(s):

Workers' Compensation and Risk Management:

• Is an up front premium required?

  Select Yes No

  • Yes
  • No

• Amount:

• Does a year-end audit typically result in additional premium due?

  Yes

  No

  N/A

• Ask for the most recent audit report.

Workers' Compensation and Risk Management Staff:

• Number of Employees:

• Average pay rate:

• Number of Hours Spent per Week:

• Briefly describe the primary duties of these employees:

Risk Assessment:

• Workers' Comp Provider:

• Workers' Comp Experience Mod: Renewal Date:

• Have you experienced any work-related injuries or other Workers' Compensation claims in the last 3 years?

  Select Yes No

  • Yes
  • No

• Please provide details:

• Who is currently responsible for work-related injury claims management?

• Do you own or lease aircraft or watercraft?

  Select Yes No

  • Yes
  • No

• Current or discontinued operations involving the storage, treatment, discharge, application, disposal or transport of hazardous materials?

  Select Yes No

  • Yes
  • No

• Any work performed underground or over 15 feet?

  Select Yes No

  • Yes
  • No

• Any work performed on barges, vessels, docks, or bridges over water?

  Select Yes No

  • Yes
  • No

• Engaged in any other type of business?

  Select Yes No

  • Yes
  • No

• Are subcontractors/independent contractors used?

  Select Yes No

  • Yes
  • No

• If yes, what % of subcontractors without coverage?

• Any work sublet without certificate of insurance?

  Select Yes No

  • Yes
  • No

• If yes, what % of work?

• Is a written safety program being utilized?

  Select Yes No

  • Yes
  • No

• Any group transportation provided?

  Select Yes No

  • Yes
  • No

• Any employees under 16 or over 60?

  Select Yes No

  • Yes
  • No

• Any seasonal employees?

  Select Yes No

  • Yes
  • No

• Any volunteer or donated labor?

  Select Yes No

  • Yes
  • No

• Do employees travel out of state?

  Select Yes No

  • Yes
  • No

• Any company sponsored athletic teams?

  Select Yes No

  • Yes
  • No

• Are physicals required post employment offers?

  Select Yes No

  • Yes
  • No

• Does your organization currently have any insurance with Zurich Financial Services?

  Select Yes No

  • Yes
  • No

• Has any coverage been declined, canceled, or non-renewal in the past 3 years?

  Select Yes No

  • Yes
  • No

• If yes, please describe:

• Are employee health plans currently provided?

  Select Yes No

  • Yes
  • No

• Is there labor interchange with any other organization?

  Yes

  No

  N/A

• Do you lease employees to and from any other employers or temp services?

  Select Yes No

  • Yes
  • No

• Do any employees predominantly work from home?

  Select Yes No

  • Yes
  • No

• Any tax liens or bankruptcy in the last 5 years?

  Select Yes No

  • Yes
  • No

• Any undisputed workers' comp premium due from you or any commonly managed or owned enterprises?

  Select Yes No

  • Yes
  • No

• If yes, entity name & policy number:

• Has your organization had any employment-related lawsuits or complaints filed in the last 5 years?

  Yes

  No

• If yes, please describe:

• Signature:

  Sign