JS LC Report 3/14

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Underwriter

• Contact Name & Title

• Contact Email Address

• Broker

• Broker Email

• Nature of Business

• Website

Description of Operations

• Does the insured employe non-English speaking employees?

  YES

  NO

• Does the insured own/operate aircraft?

  YES

  NO

• Any USL&H Exposure?

  YES

  NO

• Foreign Travel?<br>

  YES

  NO

• Turnover %

  Yes

  No

  N/A

• Are Benefits Provided

  Yes

  No

  N/A

• Unionized labor force?

  Yes

  No

  N/A

• What unions are involved

• Contract End Dates

• Total # of Employees

• # of FT

• # of PT

• # of Volunteers

• # of Temps

• Comments:

WC Class Code Description

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Average Employee age?

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Average Employee age?

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Average Employee age?

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Average Employee age?

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Average Employee age?

Exposures & Controls

• Healthcare

• Number of Licensed "Skilled" Beds

• # of Licensed "Assisted Living" Beds

• # of Licensed "Independent Living" Beds

• Lifting/ Transfers

• Infection Control

• CNA Resgistration?

  Yes

  No

  N/A

• Board Certified Nurses?

  Yes

  No

  N/A

• TB Tests Offered?

  Yes

  No

  N/A

• Hepatitis B Offered?

  Yes

  No

  N/A

• Titre Tests Completed after Hep B Series?

  Yes

  No

  N/A

• Universal Precautions?

  Yes

  No

  N/A

• Agency/ Pool Staff Used?

  YES

  NO

• Current Census & FTE- Address if Lower than average

• Comments:

Past IH Exposure

• Noise?

  YES

  NO

• Hearing Conservation Program/ Audiometric Exams?

  Yes

  No

  N/A

• Air/IAQ

  YES

  NO

• Respiratory Protection Program?

  Yes

  No

  N/A

• Comments:

PPE Requirements

• Eye/Face Protection

• Hard Hat

• Hearing Protection

• Protective Footwear

• Hand/ARM

• Respiratory Protection

• Comments

Fleet Exposures

• Does the Insured have fleet exposure?

• Cars

• # Used

• Radius

• # of Drivers

• Driven by whom?

• Small Trucks/SUV

• # Used

• Radius

• # of Drivers

• Driven by whom?

• Vans

• # Used

• Radius

• # of Drivers

• Driven by whom?

• CDL Vehicles

• # Used

• Radius

• # of Drivers

• Driven by whom?

• Other

• # Used

• Radius

• # of Drivers

• Driven by whom?

Specific UW Questions

Safety Activities

• Top Management Support?

  Yes

  No

  N/A

• Assignment of responsibility?

  Yes

  No

  N/A

• Drug Testing Program (post hire)?

  Yes

  No

  N/A

• Post Incident

• Random

• Comments:

• Safety Programs in Place?

  Yes

  No

  N/A

• Hazard Communication?

  Yes

  No

  N/A

• Forklift Operations & Training

  Yes

  No

  N/A

• LOTO

  Yes

  No

  N/A

• Machine Guarding

  Yes

  No

  N/A

• BBP

  Yes

  No

  N/A

• Fire Extinguisher Training

  Yes

  No

  N/A

• Lifting/ Ergonomics

  Yes

  No

  N/A

• Other Safety Training?

  Yes

  No

  N/A

• Safety Commitee

• Safety Committee in Place?

  Yes

  No

  N/A

• State Certified

  Yes

  No

  N/A

• Self Inspections

  Yes

  No

  N/A

• Accident Investigation

  Yes

  No

  N/A

• New Hire Screening- Check all that apply

• Application

• Interview

• References Checked

• Criminal Background Checked

• Physical Exam

• Drug Test

• Other:

• Formal Orientation

  Yes

  No

  N/A

• Required areas covered

  Yes

  No

  N/A

• General staff experience level

Return to Work Program

• Does insured currently post a panel?

  Yes

  No

  N/A

• Does Insured support light duty?

  Yes

  No

  N/A

• Are full wages paid to employees who are working light duty?

  Yes

  No

  N/A

• Is there an allowable period of time in which an employee can be on modified duty?

  Yes

  No

  N/A

Comments on Previous Large Losses

Regulatory Compliance Review

Client service needs

Recommendations

Overall Opinion of Risk

• What is your overall opinion of risk

  Select Unfavorable Average Above Average

  • Unfavorable
  • Average
  • Above Average

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