Brentwood Safety Audit

• Client

• Location Visited

• Report Recipient

• Report Prepared by

  Select

• Date

  Date

Loss Experience

• Date of Loss Runs Reviewed at Visit

• Total Number of Claims Reported

• Total Incurred Cost of Claims

Safety Management

• Designated Safety Coordinator?

  Yes

  No

• Name of designated individual?

• Written Safety Program or Safety Policies in place?

  Yes

  No

• Do all employees receive a copy of your safety policies or have access to this policy?

  Yes

  No

• Does the employee sign a document acknowledging receipt of your safety policies?

  Yes

  No

• Are newly hired employees required to complete safety orientation or training?

  Yes

  No

• Do you conduct routine safety meetings?

  Yes

  No

• Are the safety meetings documented?

  Yes

  No

• Frequency of safety meeting?

  Weekly

  Monthly

  Quarterly

  Annually

• Do you conduct back injury prevention or proper lifting training annually?

  Yes

  No

• Is there a drug testing policy established?

  Yes

  No

• Under what circumstances is drug testing performed?

  Select Post-accident Pre-employment Random For-cause and reasonable suspicion Annual physical

  • Post-accident
  • Pre-employment
  • Random
  • For-cause and reasonable suspicion
  • Annual physical

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

Claims Management

• Please keep in mind that all claims, regardless of severity, should be reported to the fund within two days of their occurrence.
  Report claims by fax at (205) 933-0375 or by email to claims@bwood.com

• Designated claims person for your entity?

  Yes

  No

• Name of designated claims individual?

• Claims reported in a timely manner (24-48 hrs)?

  Yes

  No

• Do you have a return-to-work program established and light duty positions identified when possible?

  Yes

  No

  N/A

• Do you have a Medical Protocol established that outlines approved treatment facilities?

  Yes

  No

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

• Claim Lag Time is an important element of controlling losses. Industry studies show that a claim reported beyond 48 hours following the date of the incident can increase the cost of the claim by as much as 30-40%.

Accident Investigation

• Are accidents investigated and documented using the First Report of Injury Form or required form for your state?

  Yes

  No

• Are witness statements documented during investigations?

  Yes

  No

• Is the immediate supervisor of the injured employee involved the accident investigation?

  Yes

  No

• Are the results of accident investigations as well as near misses used for training purposes to prevent future occurrences?

  Yes

  No

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

Motor Vehicle Controls

• Do you own or operated motor vehicles?

  Yes

  No

• Do you have a Motor Vehicle Operations policy that specifies license requirements, MVR requirements, and seatbelt use?

  Yes

  No

  N/A

• MVR’s reviewed upon hire and evaluated against established criteria?

  Yes

  No

  N/A

• Do you check driving records of approved drivers at a minimum of every three years?

  Yes

  No

  N/A

• Do you have an accident review board or committee established?

  Yes

  No

  N/A

• Do you have a policy concerning the use of communication devices while driving?

  Yes

  No

  N/A

• Do you conduct driver training annually covering both distracted driving and defensive driving?

  Yes

  No

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

• Locations Inspected?

• Do you conduct Self-inspections of your facilities?

  Yes

  No

• Are the inspections documented?

  Yes

  No

• Frequency of facility inspections?

  Weekly

  Monthly

  Quarterly

  Annually

General Facilities

• Exit signs posted and properly illuminated to clearly indicate exits?

  Yes

  No

  N/A

• Emergency lighting installed and in good working order?

  Yes

  No

  N/A

• All corridors, stairwells, and exits clear and unobstructed?

  Yes

  No

  N/A

• Are handrails and guardrail provided and in good condition?

  Yes

  No

  N/A

• Walkways, floors, and working surfaces free of tripping/slipping hazards?

  Yes

  No

  N/A

• Additional Recommendation?

  Yes

  N/A

• Additional Recommendation?

  Yes

  N/A

Electrical

• Is there at least three (3) feet clearance in front of electrical panels/breaker boxes?<br>

  Yes

  No

  N/A

• Are covers plates in place on electrical panels, junction boxes, etc. to eliminate exposed wiring?<br>

  Yes

  No

  N/A

• Are “WARNING HIGH VOLTAGE” signs installed on high voltage enclosures for systems rated 600V or over?<br>

  Yes

  No

  N/A

• Are all cords/plugs free from damage or deterioration?

  Yes

  No

  N/A

• Additional Recommendation?

  Yes

  N/A

• Additional Recommendation?

  Yes

  N/A

Fire Protection

• Are all self-closing doors operational?

  Yes

  No

  N/A

• Is clearance of at least 18 inches maintained around fire sprinkler heads?<br>

  Yes

  No

  N/A

• Are fire extinguishers and signs clearly visible, accessible, and unobstructed?

  Yes

  No

  N/A

• Are all extinguishers properly inspected and maintained?<br>

  Yes

  No

  N/A

• Are flammable liquids and other chemicals stored appropriately?

  Yes

  No

  N/A

• Are all flammable containers properly closed/covered to control vapors?

  Yes

  No

  N/A

• Are no smoking regulations clearly posted and being followed in “NO SMOKING” areas? <br>

  Yes

  No

  N/A

• Are all fire alarms functioning properly and tested annually?

  Yes

  No

  N/A

• Are there current welding permits displayed in welding area?

  Yes

  No

  N/A

• Additional Recommendations

  Yes

  N/A

• Additional Recommendations

  Yes

  N/A

Workshop and Service Areas

• Are workshops, service areas, and/or equipment present?

  Yes

  No

• Do you require and provide PPE?

  Yes

  No

  N/A

• Are areas requiring use of protective equipment (e.g., Eye Protection Required, etc.) adequately posted with warning signs and enforced?<br>

  Yes

  No

  N/A

• Do you require slip-resistant and/or safety toe footwear in work areas?

  Yes

  No

  N/A

• Is the required personal protective equipment worn at the time of visit? <br>

  Yes

  No

  N/A

• Is all personal protective equipment free from damage and deterioration?<br>

  Yes

  No

  N/A

• When not in use, is personal protective equipment properly maintain/stored?<br>

  Yes

  No

  N/A

• Respiratory program adequate?

  Yes

  No

  N/A

• Is self-contained breathing equipment properly maintained?/inspected?<br>

  Yes

  No

  N/A

• Do you have material handling equipment available to prevent muscle strains injuries?

  Yes

  No

  N/A

• Machine guarding satisfactory?

  Yes

  No

  N/A

• Housekeeping satisfactory?

  Yes

  No

  N/A

• Are drain openings/pits in the floor or walking surfaces guarded to prevent tripping/slipping?<br>

  Yes

  No

  N/A

• Hazard Communication Program in place?

  Yes

  No

  N/A

• Compressed gas cylinders secured in place?

  Yes

  No

  N/A

• Are protective valve caps in place when cylinder is not in use?

  Yes

  No

• Material Safety Data Sheets on file and accessible?

  Yes

  No

  N/A

• Eye wash stations and/or showers accessible, and in good working order?

  Yes

  No

  N/A

• Are spill kits accessible and fully stocked?

  Yes

  No

  N/A

• Documented lifts /crane inspections and training complete?

  Yes

  No

  N/A

• Do you perform Elevated Work?

  Yes

  No

• Are portable ladders in good repair and safe to use?

  Yes

  No

  N/A

• Are standard guardrails provided on elevated platforms?

  Yes

  No

  N/A

• Are handrails provided and in good condition on stairways or ladders?

  Yes

  No

  N/A

• Are toe-boards in place on elevated platforms to prevent objects from falling off the platform?<br>

  Yes

  No

  N/A

• Are safety harnesses worn with lanyard attached to the boom or basket when working from aerial lifts?

  Yes

  No

  N/A

• Do you own or operate heavy equipment or forklifts?

  Yes

  No

• Are inspection forms current and maintained?

  Yes

  No

  N/A

• Are load limits clearly posted in the area? <br>

  Yes

  No

  N/A

• Are operating rules clearly posted in the area?

  Yes

  No

  N/A

• Are all operators trained and authorized?

  Yes

  No

  N/A

• Is defective equipment taken out of service and tagged “DO NOT USE”?<br>

  Yes

  No

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation

  Yes

  N/A

• Additional Recommendation?

  Yes

  N/A

Recommendation Response

• Underwriting requires a documented response to the recommendations be sent, within 30 days of sending this report. Your cooperation with these matters is greatly appreciated and can have a direct effect on your contribution. Please feel free to contact your Loss Control Consultant for aid with corrective actions. Please send your response, including recommendation number and actions performed, to your loss control consultant by email.

• Recommendation Response Due Date

  Date