Facility Safety Form

• Client Name

• Conducted on

  Date

• Prepared by

• Location
  Address

• Policy Start Date

  Date

• SEIN #

• FEIN #

• # Of Employees

• WC Employee Codes

• # of Claims Last Year

Facility

• How Frequent is Safety training provided

• What States does Client Operate in

• Does the Job Site have a exit plan/signs

  Yes

  No

  N/A

• Does it look like WC codes match employees on Job site

  Yes

  No

  N/A

• Has Client been sited by OSHA in the last year

  Yes

  No

  N/A

• Do they currently have a AIP in place

  Yes

  No

  N/A

• Do they have a employed safety coordinator on site

  Yes

  No

  N/A

• Is there a Safety Incentive program in place

  Yes

  No

  N/A

• Is client aware or participate in Aflac Insurance plan

  Yes

  No

  N/A

• Do they have a return to work program option

  Yes

  No

  N/A

• Are all proper OSHA and labor law posters posted

  Yes

  No

  N/A