Premium Audit Dispute RequirementsComplete the following contact infor - PDF document

Premium Audit Dispute RequirementsComple
Premium Audit Dispute RequirementsComplete the following contact information:Policyholder Name:Policy Number:Address:Contact Name:Contact Number:If you do not agree with our audit and would like to contest it, please review the following requirements and provide the necessary supporting documentation within 30 days of final audit summary date. Disputes with supporting documentation received within 30 days of the final audit summary date will be resolved within 14 days of receipt of Note: While the prior term audit dispute is under review, you must continue to submit payments due on the current policy term to maintain coverage and avoid cancellation. IDENTIFY THE BASIS OF DISPUTE AND SUBMIT THE REQUIRED INFORMATION AS NOTED BELOW: EMPLOYEE CLASSIFICATION • Employees' name(s) • Job titles • Detailed description of job functions UNINSURED SUBCONTRACTORS or CONTRACT LABOR • Name of subcontractor/contractor • All available documentation for those subcontractors/contract labors: a) Written contract in place for each job conducted by the subcontractor/contract labor b) Detailed description of work completed c) Certificate of Workers' Compensation Insurance or a completed KEMI Independent Contractor Questionnaire d) Copy of agreement that reflects the payment of rental commission (applicable only to trucking subcontractors) • Narrative explanation of dispute • If a construction risk, detailed job cost payroll for the exposure in dispute and contracts to support the OTHER • Detailed explanation of dispute • Contract information (if applicable) Attach required supporting documentation to this form and send to: Kentucky Employers' Mutual Insurance 250 W Main Street, Suite 900 Lexington, KY 40507-1724 Fax: 859-389-3999 Email: