General Agency Services

• Audit Title

• Prepared by

• Conducted on

  Date

• Type of Survey

  Telephonic

  Physical

• Producer

• Underwriter

Insured Information

• Client / Site

• Location
  Address

• Coverage

  Select General Liability Workers Comp Commercial Auto Umbrella

  • General Liability
  • Workers Comp
  • Commercial Auto
  • Umbrella

Conferred with:

Description of Operations

Job Site Visit

• Job Site Visit Completed

  Yes

  No

  N/A

• Job site visit not conducted due to:

• Job Site Specific Observations

Employee Screening

• Who does the screening?

• Screening methods

• Written Application?

  Yes

  No

  N/A

• Criminal Background Check

  Yes

  No

  N/A

• MVR Check?

  Yes

  No

  N/A

• Past employer references?

  Yes

  No

  N/A

• Interview?

  Yes

  No

  N/A

• Pre-employment physical?

  Yes

  No

  N/A

• Pre-employment drug screening?

  Yes

  No

  N/A

• Probationary Period?

  Yes

  No

  N/A

• Random Drug and Alcohol Screening?

  Yes

  No

  N/A

• Does insured use a consortium for drug screening? If so, which one?

• Post Accident Drug Screening

  Yes

  No

  N/A

• Reasonable Cause Drug Screening?

  Yes

  No

  N/A

Oil & Gas Services

• Off

  On

• Drilling

• Drilling contractors usually have 3 shifts of drill employees that would consist of a motorman, general laborer, driller (who operates the drill controls), derrick man ( who works from heights on the rig tower), mud tender (who maintains drilling mud materials in the mud tanks), tool pusher and drilling superintendent. Exposures for a drilling contractor would include: fire and explosion hazards, falling objects hazards, fall hazards, back injuries, lifting heavy objects, rotating machinery hazards, being struck by heavy objects, overhead hazards, hose ruptures, exposures to muds and drilling fluids, unguarded machinery hazards, electrical hazards and flying objects.

• Roustabout Services

• General maintenance, painting, fence installation and repair, plumbing, changing drive belts, minor pump repair, packing bearings, changing out drive motors, replacement and repair of gathering lines.

• Lease Operator Services

• Placing the pump on the well, contracting with lease workers, contracting with trucking operations, contracting to set tank batteries.

• Pumper/ Gauger Services

• Routinely Check tank batteries for fluid levels, check on wells and compressor facilities, report gauged tank fluid levels, check well site for security, packing pump bearings with grease, changing drive belts, replacing fuses in electrical fuse boxes, repacking above- ground valves and minor repair and replacement of above ground plumbing and connections.
  
  Exposures for these employees include: falls from heights, H2S inhalation, rotating machinery hazards, electrical hazards, caught in between moving counterweights, fire hazards from propane powered pumping units.

• Fluid Hauling Services

• Hauls water from well tank batteries to disposal wells, hauls oils. Exposures include: over the road exposures, operating in remote locations, fatigued driving, distracted driving, chemical exposures, large animals (wells on cattle ranches).

• Well work-over

• Rig up a work over unit, pulls well heads, swabs, pulls out production tubing and rods, hook up well pumps, installs production tubing, set packers, cements casing.
  Exposures include: fire, rotating machinery hazards, overhead hazards, H2S hazards, perforating operations hazards, over the road driving hazards, exposures to chemicals, inclement weather hazards, high turnover.

• Dirt construction

• Construction of lease roads, digging of slush pits, preparation of drilling site, excavation and back filling of gathering lines, construct dikes, clearing of pipeline easements.
  Exposures include: heavy equipment hazards, fire, explosions, cave-ins, under ground utilities hazards, over the road driving hazards.

Operator of Wells

• Does the insured operate any wells?

  Yes

  No

  N/A

• Does insured assume any liability of contractors performing seismic operations on their behalf?

  Yes

  No

  N/A

• Does insured use IADC contract for drillers?

  Yes

  No

  N/A

• Other types of drilling contracts

  Select Turnkey Footage Day work

  • Turnkey
  • Footage
  • Day work

• Will any wells drilled have fracking?

  Yes

  No

  N/A

• Are any of the wells in PA, WV, or NY?

  Yes

  No

  N/A

• How many wells will involve fracking?

  1

  2

  3

  4

  5

• Are all wells fenced and dyked with an approved containment system?

  Yes

  No

  N/A

• Is there a formal spill prevention plan in effect?

  Yes

  No

  N/A

• Is there a formal emergency response plan in effect?

  Yes

  No

  N/A

• Are any wells near rivers, streams, lakes, etc?

  Yes

  No

  N/A

• How many?

  1

  2

  3

  4

  5

• Is a well maintenance program in effect that checks all storage tanks, flow lines, and equipment on a regular basis?

  Yes

  No

  N/A

• How often?

• Are all tanks equipped with lightning protection equipment?

  Yes

  No

  N/A

• What type?

• Are any explosives hazardous materials kept at well sites?

  Yes

  No

  N/A

• Any off shore or wet operations?

  Yes

  No

  N/A

• Environmental impact studies done on any newly acquired wells?

  Yes

  No

  N/A

Well Servicing/ Workover

• Does the insured do well servicing and/ or workover?

  Yes

  No

  N/A

• Cleaning/ swabbing?

  Yes

  No

  N/A

• Acidizing/ Fracking?

  Yes

  No

  N/A

• Hot Oiling?

  Yes

  No

  N/A

• Wireline/ Logging?

  Yes

  No

  N/A

• Installation or removal of casing?

  Yes

  No

  N/A

• Setting of packers?

  Yes

  No

  N/A

• Squeezing jobs?

  Yes

  No

  N/A

• Shooting?

  Yes

  No

  N/A

• Cementing?

  Yes

  No

  N/A

• Perforating?

  Yes

  No

  N/A

• Refinery of petrochemicals?

  Yes

  No

  N/A

• Welding/ cutting?

  Yes

  No

  N/A

• Painting, sandblasting, or tank cleaning?

  Yes

  No

  N/A

• General lease work?

  Yes

  No

  N/A

• Pipeline construction?

  Yes

  No

  N/A

• Type: steel or poly

  Select Steel Poly

  • Steel
  • Poly

• Type: gathering or transmission

  Select Gathering Transmission

  • Gathering
  • Transmission

• Type: oil or gas

  Select Oil Gas

  • Oil
  • Gas

• Type: new construction or repair

  Select new construction repair

  • new construction
  • repair

H2S Wells and Salt Water Disposal Wells

• Does the insured own any H2S wells?

  Yes

  No

  N/A

• Are all employees and contractors trained and certified on H2S awareness on an annual basis?

  Yes

  No

  N/A

• Are all H2S well sites marked with proper warning signs?

  Yes

  No

  N/A

• Do any well sites have H2S concentration levels of 10 ppm or higher?

  Yes

  No

  N/A

• Are any wells inside city limits?

  Yes

  No

  N/A

• Are gas detection devices in place?

  Yes

  No

  N/A

• Are wells fenced and gated?

  Yes

  No

  N/A

• How close is the nearest home or building?

• Who is responsible for monitoring H2S detection devices?

• How often are wells checked?

• Does the insured own any disposal wells?

  Yes

  No

  N/A
• Site name and address:
  Address

• How many acres are owned at this site?

• Is the property fenced and gated?

  Yes

  No

  N/A

• Is the site for 3rd party use?

  Yes

  No

  N/A

• Is the site lighted and posted?

  Yes

  No

  N/A

• Is there 24/7 personnel at the site?

  Yes

  No

  N/A

• Is there a formal spill prevention plan?

  Yes

  No

  N/A

• Is there an approved containment system?

  Yes

  No

  N/A

• Are any hazardous materials accepted at the sites?

  Yes

  No

  N/A

• Is there a gathering system over 6 inches?

  Yes

  No

  N/A

• Is the facility operated and maintained by employees?

  Yes

  No

  N/A

• Does the insured haul saltwater to the disposal site?

  Yes

  No

  N/A

• Surrounding exposures:

Supplying of Gas

• Does the insured supply gas to customers?

  Yes

  No

  N/A

• Commercial or residential customers?

  Select Commercial Residential

  • Commercial
  • Residential

• Is there a pressure regulator for each tap?

  Yes

  No

  N/A

• Is there a written Hold Harmless agreement in place?

  Yes

  No

  N/A

Hydraulic Fracturing

• Does the insured conduct hydraulic fracturing (fracking)?

  Yes

  No

  N/A

• Details:

Sub-contractors

• Does the insured use the services of sub-contractors?

  Yes

  No

  N/A

• Types used:

• Are certificates of insurance required and on file?

  Yes

  No

  N/A

• Does the insured require a minimum of $1 million for a sub-contractor's General Liability coverage?

  Yes

  No

  N/A

• Is there a written Hold Harmless agreement with each sub-contractor?

  Yes

  No

  N/A

• Does the insured have an approved contractor list?

  Yes

  No

  N/A

• Does the insured have Master Service Agreements with all approved contractors?

  Yes

  No

  N/A

Equipment and Tools

• Does the insured have any specific equipment or tools necessary to their line of work?

  Yes

  No

  N/A

• Types:

• Is there a formal preventative maintenance program?

  Yes

  No

  N/A

Safety

• Is there a designated Safety Director?

  Yes

  No

  N/A

• Name of Safety Director?

• Is there an Emergency Action Plan?

  Yes

  No

  N/A

• Is is reviewed regularly?

  Yes

  No

  N/A

• Reviewed by:

• Is there a Safety Incentive Program?

  Yes

  No

  N/A

• Does the insured conduct Safety Meetings?

  Yes

  No

  N/A

• Are the meetings documented?

  Yes

  No

  N/A

• How often are meetings conducted?

• Does the insured conduct Employee Safety Training?

  Yes

  No

  N/A

• Employees Safety Training provided by:

• Does the insured conduct:

• New Hire Orientation?

  Yes

  No

  N/A

• H2S training?

  Yes

  No

  N/A

• HAZCOM training?

  Yes

  No

  N/A

• Fall Hazard training?

  Yes

  No

  N/A

• Lockout/ Tagout training?

  Yes

  No

  N/A

• Blood borne pathogen training?

  Yes

  No

  N/A

• First Aid/ CPR?

  Yes

  No

  N/A

• Defensive Driving?

  Yes

  No

  N/A

• Respirator training?

  Yes

  No

  N/A

• Noise/ hearing conservation?

  Yes

  No

  N/A

• Manual Lifting?

  Yes

  No

  N/A

• Office ergonomics?

  Yes

  No

  N/A

• PPE provided:

Premises

• Owned or leased?

  Owned

  Leased

• Years at location?

• Neighborhood is:

• Estimated age of building(s):

• Number of stories:

• Square footage:

• Type of construction:

• Condition of structure:

• Number of buildings at facility:

• Air conditioned?

  Yes

  No

  N/A

• Electrical GFCI?

  Yes

  No

  N/A

• Any adjacent properties?

  Yes

  No

  N/A

Fire Protection

• Fire extinguishers?

  Yes

  No

  N/A

• Service interval and last service date:

• Smoke Detectors?

  Yes

  No

  N/A

• Service interval/ inspection:

• Pull Stations?

  Yes

  No

  N/A

• Fire Alarm?

  Yes

  No

  N/A

• Sprinkler system?

  Yes

  No

  N/A

• Standpipe or hydrant?

  Yes

  No

  N/A

• Smoking allowed in buildings?

  Yes

  No

  N/A

Security

• Building security:

• Burglar alarms?

  Yes

  No

  N/A

• Yard security:

• Worksite security:

Premises Liability- General

• Vandalism and malicious potential exists?

  Yes

  No

  N/A

• Other tenants occupy?

  Yes

  No

  N/A

• Chemical storage?

  Yes

  No

  N/A

• Clients/ general public access to facilities?

  Yes

  No

  N/A

• Tours of facility given to others?

  Yes

  No

  N/A

• Authorized personnel only allowed on premises?

  Yes

  No

  N/A

• Are restricted areas posted?

  Yes

  No

  N/A

• Vacant buildings on premises?

  Yes

  No

  N/A

• Watch dogs on premises?

  Yes

  No

  N/A

• Elevators/ hoists/ cranes?

  Yes

  No

  N/A

• Condition of facility:

• Exits marked and unobstructed?

  Yes

  No

  N/A

• Interior conditions:

• Slip and fall hazards?

  Yes

  No

  N/A

• Walkway hazards/ parking area hazards?

  Yes

  No

  N/A

• Condition of structure:

• Neighborhood is:

• Premises maintained and in good condition?

  Yes

  No

  N/A

Product Liability Exposure

• Does the insured sell any items?

  Yes

  No

  N/A

Workers Compensation

• Does the insured have a formal return to work program?

  Yes

  No

  N/A

• Who administers the return to work program?

• Does the insured have formal accident investigation procedures?

  Yes

  No

  N/A

• Who conducts the investigation?

• Does the insured have formal accident reporting procedures?

  Yes

  No

  N/A

• Who investigates near misses?

• Who conducts/ provides safety training?

• OSHA 300 log maintained by whom? What was on the log for the past year?

• Are employees exposed to high noise levels?

  Yes

  No

  N/A

• Are employees exposed to chemicals or drilling mud?

  Yes

  No

  N/A

• Are employees exposed to dust or fumes?

  Yes

  No

  N/A

• Are there high concentrations of employees at a site?

  Yes

  No

  N/A

• Are there any know occupational diseases associated with your work?

  Yes

  No

  N/A

• Are employee benefits paid by the company?

  Yes

  No

  N/A

• Are employees required to do any manual lifting?

  Yes

  No

  N/A

• Are there any office employees?

  Yes

  No

  N/A

• Are employees exposed to any radioactive substances?

  Yes

  No

  N/A

• Does the insured do any Hot Shot (expedited) delivery for others?

  Yes

  No

  N/A

• Are any employees on call after hours?

  Yes

  No

  N/A

• Does insured have a respirator program?

  Yes

  No

  N/A

• Are employees exposed to heights greater than 6 feet?

  Yes

  No

  N/A

• Does the insured have seasonal hires?

  Yes

  No

  N/A

• Does the insured lease employees to other companies?

  Yes

  No

  N/A

• Are employees required to work over water?

  Yes

  No

  N/A

Company Auto

• How many authorized drivers?

• How many CDL drivers?

• Any drivers with less than 1 year of service?

  Yes

  No

  N/A

• Driver Qualification files maintained?

  Yes

  No

  N/A

• MVRs checked?

  Yes

  No

  N/A

• By whom? How often?

• Any employees on the Do Not Drive list?

  Yes

  No

  N/A

• How is the Do Not Drive list maintained?

• Is there personal use of company vehicles?

  Yes

  No

  N/A

• Is there a written policy in effect and signed by the driver?

  Yes

  No

  N/A

• Are family members allowed to operate company vehicles?

  Yes

  No

  N/A

• Vehicle count/ type?

• Vehicles owned or leased?

  Select Owned Leased

  • Owned
  • Leased

• Average radius of travel:

• Does the insured do any trucking/ hauling for others?

  Yes

  No

  N/A

• Tow truck operations?

  Yes

  No

  N/A

• Haul hazardous materials? ( vehicles require placards )

  Yes

  No

  N/A

• Does insured have HAZMAT trained drivers?

  Yes

  No

  N/A

• Does insured transport employees to job sites in company vehicles?

  Yes

  No

  N/A

• Does insured pick up employees at home with company vehicles?

  Yes

  No

  N/A

• Haul commodities?

  Yes

  No

  N/A

• Does insured use any non-owned or hired autos?

  Yes

  No

  N/A

• Are employees required to use personal vehicles for work purposes?

  Yes

  No

  N/A

• Does insured require employees to maintain a minimum of $500,000.00 and provide proof that is maintained in office?

  Yes

  No

  N/A

• Where are company vehicles stored?

• Does each company vehicle have an accident reporting kit ?

  Yes

  No

  N/A

• Do all company vehicles have cameras inside or do company drivers have cell phones with camera capabilities?

  Yes

  No

  N/A

• Do company vehicles have Roadside Emergency Equipment?

  Yes

  No

  N/A

• Does insured have a Hands Free/ Distracted Driver policy in effect?

  Yes

  No

  N/A

• Who maintains the company fleet?

• Is there a written vehicle preventative maintenance program in effect?

  Yes

  No

  N/A

• Who maintains documentation?

Risk Quality

General Liability

• SATISFACTORY

  Satisfactory w/ suggestions

  Unsatisfactory

  N/A

• Exposures consist of fire, explosion, H2S, no written contracts, livestock damage, ungrounded tanks and electrical equipment, poor workmanship, damage to others' property, unauthorized personnel on site, lack of signage, no emergency action plan, no fluid containment, transporting explosives, radioactive equipment, ground contamination, remote locations

Company Auto

• SATISFACTORY

  Satisfactory w/ suggestions

  Unsatisfactory

  N/A

• Exposures consist of: head on collisions, side impact collisions, rear end collisions, impacts with animals, running off the road,distracted driving, fatigued driving, driving at night, driving in inclement weather, unauthorized drivers, other drivers

Workers Compensation

• SATISFACTORY

  Satisfactory w/ suggestions

  Unsatisfactory

  N/A

• Exposures for well operators include: fires, rotating machinery hazards, H2S, fall hazards, hazards associated with propane powered drive units, driving hazards
  
  Exposures for drillers and workover crews include: fire, explosion, falling objects, overhead hazards, slip and fall hazards, manual lifting injuries, caught in between heavy equipment, rotating machinery hazards, unguarded machinery, driving hazards
  
  Exposures for welders include: fire, explosions, poor ventilation, eye flash hazards,
  
  Exposures for cementing include: fire, explosions, pressure fitting rupture, dust inhalation, cement/ skin contact, exposures associated with drilling
  
  Exposures for pipeline testing include: lifting injuries, caught between injuries, pressurized line hazards
  
  Exposures for Specialty tool operations include: lifting injuries, leg and hand injuries, falling objects, slip and fall hazards, over the road driving injuries
  
  Exposures for pipeline installations include: heavy equipment hazards, unguarded machinery, fire, underground utilities, worn or damaged equipment, cave in hazards, hauling heavy equipment over the road
  
  Exposures of casing crews include: fire, explosion, delayed detonation of perforating charges, handling unused explosives, falling objects, slip and fall hazards, hazards associated with being on call 24/7, over the road driving hazards
  
  Exposures of wireline/ logging operations include: premature detonation of explosives, delayed detonation, radioactive materials, fire, explosions, over the road driving
  

Environmental Impairment Liability

• SATISFACTORY

  Satisfactory w/ suggestions

  Unsatisfactory

  N/A

• Exposures to environmental impairment include: pipeline breaks, tank truck accidents/ spills, tank battery leakage, excavation of sensitive areas,

Loss Information

• Loss information:

Management Assessment

• Loss Control Opinion of Risk:

Recommendations

• Recommendations:

Comments

• Additional remarks:

Future Service

• Follow up items:

Service Plan Schedule and Deliverables

• Task 1

  Off

  On

• Month scheduled

  Date

• Required task/ deliverable:

• Due date:

  Date

• Follow up required?

  Yes

  No

  N/A

• Task 2

  Off

  On

• Month scheduled

  Date

• Required task/ deliverable:

• Due date:

  Date

• Follow up required?

  Yes

  No

  N/A

• Task 3

  Off

  On

• Month scheduled

  Date

• Required task/ deliverable:

• Due date:

  Date

• Follow up required?

  Yes

  No

  N/A