Commercial Inspection WC

• Applicant Business Name

• Policy Number

• Log No.

• Conducted on

  Date

• Engineer

  Select Bruce Krug Adam Dunmire Denny Homaday Jeff Vehovic Denny Weimer Jim Leer Pete Calabrese Gary Galley David Friedline Joe Nicoletti

  • Bruce Krug
  • Adam Dunmire
  • Denny Homaday
  • Jeff Vehovic
  • Denny Weimer
  • Jim Leer
  • Pete Calabrese
  • Gary Galley
  • David Friedline
  • Joe Nicoletti
• Inspection Location
  Address

• Agent

Policy Inspection Information

• Type of Inspection

  Select New Renewal Quote Pre-Inspect Binder

  • New
  • Renewal
  • Quote
  • Pre-Inspect
  • Binder

• Underwriter

  Select Andrea Arnold Barry Thomas Bonny Specht Cathy Haer Debra Shaulis Joe Difebo John MIller Kelly Geary Kurt Tipton Marth Stutzman Ron Davidson Tammy Snyder Valerie Kleinert

  • Andrea Arnold
  • Barry Thomas
  • Bonny Specht
  • Cathy Haer
  • Debra Shaulis
  • Joe Difebo
  • John MIller
  • Kelly Geary
  • Kurt Tipton
  • Marth Stutzman
  • Ron Davidson
  • Tammy Snyder
  • Valerie Kleinert

Business Info

• Mailing Address
  Address

• Business Operation

• Business hours

• History

• Business Structure

  Corporation

  Individual

  Partnership

  Other

• Corporate officers: If corporation exempt:

  Yes

  No

  Uncertain

• Explain:

• Individuals, Partners Included (NCCI states only)

  Yes

  No

  Uncertain

• Name, TItle, Duties and Payroll

Name

• Partner/Individual

• Title

• Duties

• Payroll

  Select $500-$5000 $5000-$10,000 $10,000-$25,000 $25,000-$50,000 $50,000-$75,000 $75,000-$125,000 $125,000-$225,000 Uncertain

  • $500-$5000
  • $5000-$10,000
  • $10,000-$25,000
  • $25,000-$50,000
  • $50,000-$75,000
  • $75,000-$125,000
  • $125,000-$225,000
  • Uncertain

• Other Locations or Business/Entities Commonly Owned, T/A's, D/B/A's, etc.

  Yes

  No

  Uncertain

• Explain:

• Interchange of labour between entities

  Yes

  No

Employees

• Wages

  Select Salary Hourly Piece Rate Incentive Flat Rate Other

  • Salary
  • Hourly
  • Piece Rate
  • Incentive
  • Flat Rate
  • Other

• Explain:

• Percentage of Employee Turnover

• Employee Avg Experience (Years)

• Employee Avg Age (Years)

• New employee screening/training probation period.

  Yes

  No

• Explain:

• Post Offertory physical examinations required

  Yes

  No

• Explain:

• Drug alcohol testing

  Yes

  No

• Explain:

• Eligibility of employment verified

  Yes

  No

• Is English only language spoken

  Yes

  No

• Handicap employees

  Yes

  No

• Explain:

• Union operation

  Yes

  No

• Explain:

• Seasonal operation/Employees

  Yes

  No

• Explain:

Hazards/Exposures

• Severity Hazard:

• Frequency Hazard:

• O.D Exposure

  Yes

  No

• Explain:

• Excessive noise levels

  Yes

  Intermittent

  No

• Explain:

• Is Audio metric testing done

  Yes

  No

• Weight lifted

  0-10

  11-25

  26-50

  51-100

  100+

• Prolonged/Repetitive exposures to:

  Select Forceful Exertions Environmental Vibrations Repetitive Motions Awkward Static Postures Contact Stress Lifting Externally Paced Operations Rapid Hand/Wrist Other:

  • Forceful Exertions
  • Environmental
  • Vibrations
  • Repetitive Motions
  • Awkward Static Postures
  • Contact Stress
  • Lifting
  • Externally Paced Operations
  • Rapid Hand/Wrist
  • Other:

• Explain:

• Overhead:

  Yes

  No

• Explain:

• Excavation Underground:

  Yes

  No

• Explain:

• Work at heights:

  Yes

  No

• Written fall protection policy:

  Yes

  No

• Fall protection methods:

• Ladders/scaffolding/manlifts:

  Daily

  Incidental

  No

• Ladders/scaffolding/manlifts safety practices:

  Yes

  No

• Explain:

• Flammable liquids/hazardous materials:

  Yes

  No

• Explain:

• MSDS Available:

  Yes

  No

• Hazard communication training:

  Yes

  No

• Pressurized vessels:

  Yes

  No

• Explain:

• Blasting

  Yes

  No

• Explain:

• Hot liquids/metals:

  Yes

  No

• Explain:

• Extreme Heat:

  Yes

  No

• Explain:

• Blood Borne Pathogens:

  Daily

  Incidental

  No

• Explain:

• Confined Spaces:

  Yes

  No

• Explain:

• Slips, Trips and Falls:

• Control/Prevention Practices:

Premises

• Type of Area/Neighborhood:

  Residential

  Commercial

  Rural

  Industrial

• Condition of Area/Neighborhood:

  Good

  Fair

  Poor

• Adjacent/Nearby Hazards/Exposures:

• Housekeeping:

  Good

  Fair

  Poor

• Describe:

• Sanitation:

  Good

  Fair

  Poor

• Explain:

• Condition of Facility:

  Maintained

  Deteriorating

• Explain:

• Water seepage/Damage, Leaking Pipes, Damp Areas and/or Musty/Earthy Odors:

  Yes

  No

• Explain:

• Fire Protection:

  Yes

  No

• Explain:

• Ventilation

  Good

  Fair

  Poor

• Explain:

Off-Premises

• Work away from premises:

  Yes

  No

• Explain:

• Employee transportation provided:

  Yes

  No

• Explain:

• Out of state operations:

  Yes

  No

• Explain:

• Employees hired that reside in other states:

  Yes

  No

• Explain:

• Any operating, ownership, leasing, borrowing, usage or any other involvement with any aircraft?

  Yes

  No

• Explain:

Equipment

• Major equipment used:

• Adequate guarding of equipment and machinery:

  Yes

  No

• Explain:

• Written lockout tagout policy:

  yes

  no

  N/A

• Explain:

Safety Practices/Procedures

• Safety Precautions:

• Safety Committee

  Yes

  No

• Safety Committee PA Certified:

  Yes

  No

• Explain:

• First Aid KIt Supplies:

  Yes

  No

• First Aid/EMT/CPR Training:

  Yes

  No

Recommendations

• Engineers Recomendations:

Comments:

• Engineers Comments:

Opinions

• Cooperative:

  yes

  no

  N/A

• Explain:

• Inspectors opinion of risk:

Photos

• Add media

  Media