Fillable Printable Form 213-177-000
Fillable Printable Form 213-177-000
Form 213-177-000
Page 1 of 4 F213-177-000 Pre-Audit Questionnaire 7/2010
Pre - Audit Questionnaire
Firm Information
Firm Name: Business Start Date: Firm’s Phone number:
Firm Street Address: Audit Point of Contact: Audit POC Phone number:
City / State / Zip: Unified Business Identifier (UBI#): L&I Account #:
Employment Security
Account #:
Contractor Registration #: Expiration
Date:
Email Address:
Website Address:
Name of Bank: Bank Acct #: Branch Location:
Business Organization
Sole ProprietorshipCorporationPartnership
LLC
Has there been any change in ownership in the
past four years?
Yes No
Date of formation: State of formation :
Do you (the owners/officers) perform any work for the firm?
NoYes
Do you report owner / partner / officer / member – manager work hours to Labor & Industries?
Yes No
Effective Date as
Owner/Officer/Member - Manager
Name(s)
Title Social Security # Officer Shareholder Stock %
Name:
Work Performed:
Name:
Work Performed:
Name:
Work Performed:
In detail describe your business activities:
9/29/2010
Print Form
Page 2 of 4 F213-177-000 Pre-Audit Questionnaire 7/2010
Worker Information
How do you pay your workers?
Cash Check Direct Deposit
Other
What is the basis for their pay?
Hourly Piecework Salary Commission
Do you deduct the employee portion of industrial insurance premium from employee paychecks? NoYes
HOURLY / PIECE WORK EMPLOYEES
Do any employees receive pay for holiday, sick, vacation, or
any other time away from work?
No
Yes
Do you deduct employee vacation or sick leave from the total
hours reported to Labor & Industries?
No
Yes
Do any employees receive pay for holiday, sick,
vacation, or any other time away from work?
No
Yes
Do you deduct employee vacation or sick leave from the
total hours reported to Labor & Industries?
No
Yes
SALARY / COMMISSION EMPLOYEES
Do you have any workers who perform clerical office (4904), outside sales/estimator (6303), or construction superintendent duties (4900)?
No
Yes
If so, which risk classes are these hours reported in?
Do you pay workers for travel time?
No
Yes
Have hours for any worker been divided between two or more risk classifications?
If so, which risk classes are these hours reported in?
No
Yes
Job Descriptions
(Attach additional page if needed)
Job Title:
Risk Classification:
Job Duties
Job Title:
Risk Classification:
Job Duties
Job Title:
Risk Classification:
Job Duties
Job Title:
Risk Classification:
Job Duties
9/29/2010
Page 3 of 4 F213-177-000 Pre-Audit Questionnaire 7/2010
Subcontractor / Independent Contractor Information
(Attach additional page if needed)
Please list all individuals or businesses that performed services for your business that are not on your payroll.
Examples would be individuals/businesses you issue IRS form 1099, casual/temporary labor, janitorial services, lawn care services, computer
services, plumbing services or other repair services. Please be prepared to supply the supporting documentation at the time of the audit.
Subcontractor Information Contract Information
Name of
Subcontractor
Address Location
UBI #
L&I Acct
#
Amount Paid
During Audit
Period
Did the
subcontractor
bring workers?
Yes/ No
Brief Description/Nature of
Contract Work
Contractor's
Lic #
For Example:
NW Contractors
123 Ash Ave,
Seattle, WA 98122
601 344 567
211, 707
- 00
nwcont*235
Roofing, Inside Carpentry Yes $57,800
9/29/2010
Page 4 of 4 F213-177-000 Pre-Audit Questionnaire 7/2010
Contractor Information
(Attach additional page if needed)
Please list all contractors that hired your firm during the audit period.
Name: Unified Business Identifier (UBI): Phone #:
I, the undersigned, declare that I am the authorized representative of the firm submitting this questionnaire and that the
answers contained, including any accompanying information, have been examined by me and that the matters and things set
forth are true, correct and complete.
Signature required (if a corporation, corporate officer must sign)
Title: Date:
9/29/10
