RTS Audit Order Form

Research Technical Services, Ltd.

Serving the Insurance Industry

Audit Request Form: You must click SUBMIT to send us your request.

Remember to PRINT the page for your records.

INSURANCE COMPANY NAME: *		RTS ACCOUNT#: *		REQUESTOR'S NAME: *

		POLICY #1: *				POLICY #2:

		INSURED OR BUSINESS NAME: *		INSURED'S PHONE#:

		STREET ADDRESS

		CITY		STATE		ZIP CODE

		PHYSICAL AUDIT ADDRESS

		CITY		STATE		ZIP CODE

		CONTACT'S NAME:		CONTACT'S PHONE:		TYPE?

		DUE DATE :				ORDER DATE :

		AGENT/AGENCY:		TELEPHONE:

POLICY TYPE : *

WORKERS COMP

GENERAL LIABILITY

GARAGE LIABILITY HAZ I

GARAGE LIABILITY HAZ II

COMMERCIAL AUTO

OTHER (Please Specify)

AUDIT TYPE : *

PHYSICAL

SPECIAL (Documentation)

TELEPHONE

INTERIM (Specify Length)

		POLICY START DATE :		POLICY END DATE :

		ESTIMATED EXPOSURE BY CLASS: CODE - - - - - - CLASSIFICATION - - - - - - - - - - - AMOUNT (Payroll/Sales/Units)

		OFFICER / OWNER - INCLUSION / EXCLUSION:

		SPECIAL INSTRUCTIONS / CLAIMANT INFO:

* Required to submit this form

Research Technical Services Ltd.
A Company Expanding the Service Role