Turner CCIP On-Site Payroll Report Kansas City Wizards ...

1 FORMS Turner CCIP On-Site Payroll Report Form-4 Kansas City Wizards Stadium Page 1 of 2 Numbers reference attached instructions Complete a Separate Form for Each Contract with Turner CCIP. Your Report is due to the Aon Insurance Administrator, identified below, no later than the 10 day of the succeeding month. thComplete this Report even though no work was performed; enter zero (0) for the Reportable Payroll . Delay in providing this Report may result in payments being withheld. A. Report IDENTIFICATION 1 2 3 Year: Period Beginning: Period Ending: 4 Contractor: 5 Under Contract with: Turner Construction Company CCIP Insurance Manual Final Version 2/17/10 40 Kansas City Wizards Stadium Kansas City, Kansas Contract #: 6 B. ACTIVITY Report b a State Workers Compensation c d e f Class Code Work Description Man-Hours Gross Payroll Reportable Payroll * 1 2 3 4 TOTALS: * Do not include premium (excess) overtime wages, use straight time wage rates only.

2 C. ADDITIONAL DATA REQUIREMENTS : 1. 2. 3. D. Signature Block : I verify the information presented above and attachments are correct: Name: Date: (please print) Title: Signature: CHECK IF THIS IS YOUR LAST Payroll Report . COMPLETE AN AON FORM-5 NOTICE OF WORK COMPLETION AND INCLUDE WITH THIS Payroll Report . : Information can be submitted on-line at . Please contact your Administration Staff to obtain a User ID and Password. NOTE: ALL PAYROLLS ARE TO BE SUBMITTED NO LATER THAN THE 10TH OF THE MONTH FOLLOWING. Fax or Email to: AON RISK SERVICES, Turner CCIP SERVICE CENTER Fax: 800-363-6695 Email: 12/13/7/2012 Sample 2001No WorkSample Requirement 2 Sample37-1371371 ManagerSample 3 Points North (CPW Sample Reports)John DoeSample Requirement 33/72011 Sample 1 Stable Work 2904 Sample Requirement 1 Complete a Separate Form for Each Contract with Your Report is due to the Aon Insurance Administrator, identified below, no later than the 10th day of the succeeding each month.

3 Complete this Report even though no work was performed; enter zero (0) for the Reportable Payroll . Delay in providing this Report may result in payments being withheld.