Big Dummy Loss Control Survey

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Description of Operations

• Years in business?

  Yes

  No

  N/A

• Any other businesses owned by this insured?

  Yes

  No

  N/A

• Radius of travel.

  Miles

• Any work beyond domicile state?

  Yes

  No

  N/A

• If out of state work, do they hire out of state employees?

  Yes

  No

  N/A

• Employees paid on W2 or 1099?

  Yes

  No

  N/A

• Risk Properly Classified?

  Yes

  No

  N/A

Stonewood Specific

• Any employees over the age of 60?

  Yes

  No

  N/A

• Any employees under the age of 16?

  Yes

  No

  N/A

• Owners/Officers Inclusion/Exclusion correct on policy?

  Yes

  No

  N/A

• Are Health Insurance benefits provided to employees?

  Yes

  No

  N/A

Number of Employees and Payroll information?

Hiring Practices

• Turnover?

  Yes

  No

  N/A

• Written applications obtained?

  Yes

  No

  N/A

• Per-Employment Drug Testing Conducted?

  Yes

  No

  N/A

• Pre-Hire Interviews Conducted?

  Yes

  No

  N/A

• MVR Checks Conducted on Drivers?

  Yes

  No

  N/A

• Reference Checks Conducted

  Yes

  No

  N/A

Subcontractors

• Any work subcontracted out?

  Yes

  No

  N/A

• Percentage of work subcontracted out?

  Narrative

• Any uninsured subs used?

  Yes

  No

  N/A

• COI's obtained?

  Yes

  No

  N/A

Safety Programs

• Written Safety Program in place?

  Yes

  No

  N/A

• Safety Meetings Conducted and Documented?

  Yes

  No

  N/A

• Safety Committee?

  Yes

  No

  N/A

• Written Accident Investigations Conducted?

  Yes

  No

  N/A

• Safety Incentive Program in Place?

  Yes

  No

  N/A

• Fall Protection Program

  Yes

  No

  N/A

• Confined Space Training

  Yes

  No

  N/A

• Ladder & Scaffold Safety Training

  Yes

  No

  N/A

• LOTO Program in place?

  Yes

  No

  N/A

• Equipment Operator Training & Certification

  Yes

  No

  N/A

Personal Protective Equipment (PPE)

• Lack of, or inadequate PPE (including sun protection)

  Safe

  At Risk

  N/A

• Lack of training in safe use, clean-up and inspection of PPE?

  Safe

  At Risk

  N/A

• Lack of system to issue, inspect, replace and monitor PPE?

  Safe

  At Risk

  N/A

Plant / Jobsite

• Condition of Facilities

  Safe

  At Risk

  N/A

• General Housekeeping

  Safe

  At Risk

  N/A

• Condition of Equipment/Machinery Machine Guarding

  Safe

  At Risk

  N/A

• Unlicensed operators?

  Safe

  At Risk

  N/A

• Lack of safe work instructions?

  Safe

  At Risk

  N/A

• Lack of training in safe operation, clean-up and maintenance?

  Safe

  At Risk

  N/A

• Lack of LOTO procedures for cleaning, servicing and maintenance?

  Safe

  At Risk

  N/A

• Lack of inspection regime?

  Safe

  At Risk

  N/A

• Inadequate housekeeping?

  Safe

  At Risk

  N/A

• Lack of, or inadequate noise/ vibration control?

  Safe

  At Risk

  N/A

• Insufficient lighting?

  Safe

  At Risk

  N/A

Working at Heights

• Fall risks of 6 ft. or more? (including voids, pits, and trenches)

  Safe

  At Risk

  N/A

• Unsafe or Damaged Ladders?

  Yes

  No

  N/A

• Lack of edge protection?

  Safe

  At Risk

  N/A

• Ladder safety training given to employees?

  Yes

  No

  N/A

• Unsafe Positioning of ladders?

  Yes

  No

  N/A

• Ladders not properly secured?

  Yes

  No

  N/A

• Ladder unsuitable for job?

  Yes

  No

  N/A

• Unlicensed persons erecting scaffold above 4m?

  Safe

  At Risk

  N/A

• Unsafe or incomplete scaffold?

  Safe

  At Risk

  N/A

• Lack of inspection protocol for scaffold?

  Safe

  At Risk

  N/A

• Incompatible scaffold components? Unlabelled or do not meet AS?

  Safe

  At Risk

  N/A

• Safe Work Load (SWL) exceeded? (tools, stored materials, number of persons)

  Safe

  At Risk

  N/A

Lifting Equipment

• 4.2. Loads lifted over persons, close proximity to obstacles incl. overhead power lines?

  Safe

  At Risk

  N/A

• 4.3. Lack of maintenance, testing and inspection?

  Safe

  At Risk

  N/A

• 4.4. Lack of SWL information displayed?

  Safe

  At Risk

  N/A

• 4.5. Lack of daily inspection protocol?

  Safe

  At Risk

  N/A

• 4.6. Unsafe or damaged lifting equipment, including ropes, slings, chains, hooks?

  Safe

  At Risk

  N/A

• 4.7. Lifting equipment unlabelled, does not meet AS, no SWL displayed?

  Safe

  At Risk

  N/A

• 5.6. Lack of or inadequate formal training for operators?

  Safe

  At Risk

  N/A

• 4.8. Unlicensed operators?

  Safe

  At Risk

  N/A

• 4.9. Lack of LOTO procedures for cleaning, servicing and maintenance?

  Safe

  At Risk

  N/A

Electrical Hazards

• 13.1. Unsafe electrical leads? (damaged, out of test date or untested)

  Safe

  At Risk

  N/A

• 13.2. Lack of RCD protection?

  Safe

  At Risk

  N/A

• 13.3. Contact with underground assets?

  Safe

  At Risk

  N/A

• 13.4. Contact with overhead electrical lines?

  Safe

  At Risk

  N/A

• 13.5. Overloading outlets?

  Safe

  At Risk

  N/A

• 13.6. Leads placed on ground or on metal structures?

  Safe

  At Risk

  N/A

• 13.7. Electrical equipment near water?

  Safe

  At Risk

  N/A

• 13.8. Electrical equipment near flammables?

  Safe

  At Risk

  N/A

• 13.9. Electrical equipment near chemicals that could cause damage?

  Safe

  At Risk

  N/A

• 13.10. Electrical leads that may be damaged from contact with moving machinery parts?

  Safe

  At Risk

  N/A

• 13.11. Electrical leads on work surfaces?

  Safe

  At Risk

  N/A

• 13.12. Lack of Lock-out/tag-out (LOTO) procedures for electrical equipment?

  Safe

  At Risk

  N/A

Hazardous Chemical (including fuel and oil)

• 8.1. Unsafe storage location? (e.g. flammables near ignition sources, spills could enter stormwater drains, etc)

  Safe

  At Risk

  N/A

• 8.2. Incompatible chemicals stored near each other?

  Safe

  At Risk

  N/A

• 8.3. Inadequate spill containment equipment?

  Safe

  At Risk

  N/A

• 8.4. Safety Data Sheets not accessible on site?

  Safe

  At Risk

  N/A

• 8.5. Lack of emergency procedures for injury/spills/fire etc?

  Safe

  At Risk

  N/A

• 8.6. Excessive quantities stored on site or in vehicles?

  Safe

  At Risk

  N/A

• 8.7. Insufficient ventilation?

  Safe

  At Risk

  N/A

• 8.8. Insufficient, or incorrect, PPE?

  Safe

  At Risk

  N/A

• 8.9. Unsuitable storage containers? (unlabeled or stored in food containers)

  Safe

  At Risk

  N/A

Claims Summary

Loss Analysis & Trends

Opinion of Risk

Corrective Actions

• Enter any corrective actions that will be undertaken

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