Replacement Self-Audit Forms for Premium Audit

In the event the pre-addressed policy specific form we sent you has been lost or misplaced, you may download and print off one of the blank forms below as a replacement.

Underwriting Forms & Applications

Get Adobe ReaderIn order to view and print these forms you must have a version of Adobe Acrobat Reader® installed on your computer. The latest version of Adobe Acrobat Reader® is free and can be downloaded and installed from the following address: http://www.adobe.com/products/acrobat/readstep2.html

Workers' Compensation Self-Audit Form Download Type
This is a blank self-audit payroll form for Workers' Compensation policies.
General Liability Self-Audit Form  

This is a blank self-audit form for General Liability policies. This can be used for any classifications where the premium basis is one of the following: payroll, sales (receipts), gallonage or cost (total payments to subcontractors). If you have other types of classifications based on area of square footage which do not routinely change, there is no need to report these items. These later items are not typically subject to audit or adjustment.
Garage Liability Self-Audit Form  
This is a blank payroll self-audit form for garage/service stations, rated on payroll.
Auto Dealer Inventory Reporting Form
  
This is a blank monthly (or quarterly) inventory report for Franchised Auto Dealers' physical damage coverage.

Fill the information in exactly as it is shown on your policy and sign the document. You may then return a copy of the completed form by sending it to the address or fax number shown below.

Utica National Insurance Group
Attn: Home Office Premium Audit
P.O. Box 530
Utica, NY 13503

FAX: 315-266-4043

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E-mail webmaster@uticanational.com; Copyright 2003-2008. Utica Mutual Insurance Company: 1-800-274-1914. All Rights Reserved. Legal Notices