07/01/ /01/2012 Serial # Arthur J Gallagher Risk Management Serv. Auditor BYRON CENTER PUBLIC SCHOOLS. Mark Faber, BUSINESS MANAGER
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1 Policy # BCPS Carrier Arthur J Gallagher Risk Management Serv Auditor Charles Dyksterhouse Policy Period 07/01/ /01/2012 Serial # Insured BYRON CENTER PUBLIC SCHOOLS Date 09/11/2012 Audit Period 07/01/ /01/2011 Policy Type: Workers Compensation Audit Type: Annual Audit Source: Physical Legal Entity: Non-profit Org. Federal ID#: Ins. Name 2: Insured Location: 8542 BYRON CENTER AVE SW BYRON CENTER, MI Insured Phone: Audit Location: 8542 BYRON CENTER AVE SW BYRON CENTER, MI Audit Phone: Source of Data Payroll Book Cash Book Check Book Gen'l Ledger Gen'l Journal W/C Summary Verification S/S Returns U/C Returns Income Tax Financial State. Subcontractors Yes No Condition Good Fair Poor Time Charges Travel: Direct: 2.00 Write-up: Audit Contact: Mark Faber, BUSINESS MANAGER Insured is a school district located in Byron Center, Michigan. Insured operations are 6 public school buildings, 1 athletic field, 1 bus garage and storage lot and 1 administration building. Student enrollment is 3158 Students. Employees that provide direct instructional contact with students such as teachers, teacher aids, administrators, superintendents' librarians, library clerks and driving instructors. ( Professional/Teachers) Employees that perform primarily departmental supervision, administration secretarial functions such as bookkeeping, scheduling, data entry, auditing, designing and maintaining financial, staff, pupil, program or property records, summarizing, analyzing or verifying such records. ( Clerical) Custodial functions are school plant housekeeping and servicing consisting of such activities as cleaning, operating heating, ventilating and air conditioning systems, caring for school property and servicing building equipment. ( Janitorial) Vehicle operation involves the driving of a vehicle such as a school bus, truck or automobile used Transport students from the neighborhoods in the school district to the schools ( Bus Drivers) Food service employees prepare meals on the school premises (9058-Food Service) Miscellaneous employees are employees that are not otherwise classified in one of the other codes used by the WMWCF that would include all employees performing vehicle maintenance including supervisory and clerical personnel located in the garage facility. Other operations that are included in this code are lunchroom supervisor, equipment managers, playground supervisors, mail delivery person, graphics/copy machine operators, dispatchers, security guards and hall monitors. ( All other) GENERAL NOTES: Audit was conducted at the insured's administrative office All records and documents requested by the auditor were provided by the insured Records audited; General ledger showing expenditures (Object/Activity codes ), WC Summary Report and Payroll Employee Analysis Payroll has been verified to IRS Form 941, line 5 Cash in Lieu of benefits to be excluded per customer agreement. DESCRIPTION OF OPERATIONS Exit interview was conducted with Mr. Mark Faber, Mr. Faber agreed with the audit results. At the time of the exit interview a copy of the OLSI was presented to Mr. Faber in lieu of ing or Faxing a copy to him VISUAL SOFTWARE LLC Page 1 of 6 Overland Solutions
2 Policy # BCPS Serial # TITLE NAME Carrier Insured ADJ. GROSS PAYROLL Arthur J Gallagher Risk Management Serv BYRON CENTER PUBLIC SCHOOLS AMOUNT INCLUDED Auditor Charles Dyksterhouse Date 09/11/2012 Policy Period Audit Period DAYS STATE CODE DESCRIPTION OF DUTIES 07/01/ /01/ /01/ /01/2011 Govern by a elected Board of Education who are not compensated and not active with day to day operations. Gross Wages MI excl AUDIT SUMMARY VERIFICATION SUMMARY CLASSIFICATION CODE EXPOSURE PAYROLL EXPOSURE BYRON CENTER PUBLIC SCHOOLS - MI - 07/01/11 to 07/01/12 - BYRON CENTER Drivers ,652 Clerical ,141,570 Professional/Teachers ,825,442 Janitorial ,710 Food Service ,642 All Other ,693 TOTAL 16,655,709 Gross Wages 16,703,834 Less Adjustments (48,124) TOTAL 16,655,710 Gross Wages Figures Code Name 07/01/11-07/01/12 GROSS Ot Prem Pay Cash in lieu From W/C Summary BYRON CENTER PUBLIC SCHOOLS - MI - BYRON CENTER 7380 Drivers Clerical Professional/Teachers Janitorial Food Service All Other excl SUBTOTAL GRAND TOTAL Gross Wages Verification 3rd Qtr '11 4th Qtr '11 1st Qtr '12 2nd Qtr '12 Accruals TOTAL 2000 VISUAL SOFTWARE LLC Page 2 of 6 Overland Solutions
3 Policy # BCPS Carrier Arthur J Gallagher Risk Management Serv Auditor Charles Dyksterhouse Policy Period 07/01/ /01/2012 Serial # Insured BYRON CENTER PUBLIC SCHOOLS Date 09/11/2012 Audit Period 07/01/ /01/2011 Gross Wages Verification (604831) Gross Wages Recap for BYRON CENTER PUBLIC SCHOOLS - MI - 07/01/11 to 07/01/12 - BYRON CENTER Recap TOTAL Excluded Gross Payroll Less Ot Prem Pay (13544) (13544) Less Cash in lieu (34580) (34580) Less excl 0 Principal Min/Max/Flat 0 TOTAL Code Name Number of Employees GROSS BYRON CENTER PUBLIC SCHOOLS - MI - BYRON CENTER 7380 Drivers Clerical Professional/Teachers Janitorial Food Service All Other SUBTOTAL Nimber of employees Figures GRAND TOTAL VISUAL SOFTWARE LLC Page 3 of 6 Overland Solutions
4 Overland Solutions, Inc. Audit Checklist - Page 1 of 2 Insured BYRON CENTER PUBLIC SCHOOLS Policy # BCPS Date Audited 09/11/12 Obtain the information necessary to answer the following questions. Boxes with an asterisk () require an explanation in the box below the applicable question (or information in the Description of Operations/adjustments sections as directed). Explanations must include what was discovered and how the situation was handled. Y N N/A 1) Were there multiple entities, locations or named insured's? If Yes, was each individually addressed in the Description of Operations? Yes No 2) Has each classification been supported and shown in the Description of Operations (including new or discontinued classifications, and those with zero exposure or written on an "if any" basis")? 3) Have all officers/principals been listed, duties described, ownership percentage provided and 100 percent accounted for? Govern by an elected Board of Education who's members are not paid and they are not active in day-to-day activities 4) Were Standard Exception employees listed individually (up to 10 per Standard Exception) and duties properly described? Over 20 Standard Exception employees 5) Were key employees (e.g. supervisors, managers, quality control, etc.) identified separately in worksheets and duties properly described? Payroll is presented by expenditure Object/Activity Code as defined by the State of Michigan Board of Education 6) Were any goods or materials delivered/hauled by: Employees? Owner/Operators? Supplies and students are transported 7) Were there any: Aircraft Operations? (Provide number of passenger seats in audit summary) USL&HW, Jones Act or other maritime operations of any kind? Volunteer Workers? Leased or temporary employees? Domestic employees in Principal's home? Insured does not maintain records of dates or hours worked by Volunteer Workers 8) Were any general exclusion operations conducted (new construction, stevedoring, sawmill, daycare, state special)? If Yes, provide details in Description of Operations.
5 Overland Solutions, Inc. Audit Checklist - Page 2 of 2 Insured BYRON CENTER PUBLIC SCHOOLS Policy # BCPS Date Audited 09/11/12 Obtain the information necessary to answer the following questions. Boxes with an asterisk () require an explanation in the box below the applicable question (or information in the Description of Operations/adjustments sections as directed). Explanations must include what was discovered and how the situation was handled. Y N N/A 9) Were there any exposure base adjustments such as (overtime, commissions, tips, severance [payroll], sales taxes, returns and allowances, inter-company sales [sales], etc)? If yes, were adjustments shown in worksheet? Yes No 10) Was there a 401K, Café 125 or other pre-tax benefit plan during the policy term? If yes, were adjustments shown in worksheet verification/reconciliation section? Yes No Amounts paid are included in the quarterly gross wages. 11) Was any subcontract or other non-employee labor used? If Yes, explain in the Description of Operations. Were certificates of insurance reviewed? 12) Were any jobs subject to OCIP or Waiver exclusion? If Yes, show adjustments in worksheet and provide job and certificate of insurance details below. Yes No (comment in Description of Operations) 13) Was a claims list attached? If Yes, provide claims verification detail below. A loss run was not attached to the audit request. 14) Exit interview conducted with: Mark Faber Title: No concerns. Concerns noted below. BUSINESS MANAGER Auditor: Charles Dyksterhouse Work Order ID:
6 Insured BYRON CENTER PUBLIC SCHOOLS Policy # BCPS Date Audited 09/11/12 UNDERWRITING REFERRAL CLASSIFICATION CHANGES: ADD CODE #'s: DELETE CODE #'s: MULTI STATE POLICY: ADDED STATES: DELETED STATES: ENTITY CHANGE: CORPORATION PARTNERSHIP INDIVIDUAL OTHER: NAME: DATE: OFFICERS/OWNERS CHANGED/ADDED/DELETED ADDRESS/LOCATION CHANGE/DELETION/ADDITION ACTUAL EXPOSURES AS COMPARED TO ESTIMATED EXPOSURES VARY BY MORE THAN 20% UNINSURED OR UNDERINSURED SUBCONTRACTOR EXPOSURE FOUND DURING AUDIT. SEE SUB. DETAIL EMPLOYEE LEASING DISCLOSED EVIDENCE OF FINANCIAL DISTRESS AUDIT REVISED AUDIT DATA QUESTIONABLE DUE TO: COMMENTS: Variance between the estimated and audited payrolls reflect the vairance in funding that the insured experiences from year to year. Insured expects the current payroll to approxmate the audited. STATE: Code: Policy Estimate: Audited Figures: Difference (+ or -): MISC. INFO: ASSISTED INSURED TO ESTABLISH APPROPRIATE RECORDS FOR FUTURE AUDITS COMMUNICATED WITH AGENT REGARDING ACCOUNT COMMUNICATED WITH UNDERWRITING OR MARKETING REGARDING ACCOUNT Variance % (+ or -): MI MI MI MI MI MI TOTAL If 5 or fewer codes, show all codes in the Variance Analysis section, with TOTALS of audited and estimated figures in the bottom row. If > 5 codes, show only those with > 20% variance (and no TOTALS). If adding a new code, or code written on an "if any" basis with an audited exposure, input.001 for the policy estimate. If policy written on an 'if any' basis, and there is no exposure, input 0 for the estimate.
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