Loss Control Inspection Template

• Survey Type

  Select

• Account Name:

• Account Number

• Policy Number(s):

• Address:
  Address

• Type of Business:

  Select

• Contact Name/Title:

• Contact Phone Number:

• Contact Email:

• Consultant's Name:

  Select

• Underwriter:

  Select

• Additional UW questions or concerns (If yes, add questions/concerns in the notes section)

  Yes

  No

  N/A

  Unknown

• Need date:

  Date

• Survey conducted date:

  Date

• Report date:

  Date

• Agency/Producer:

  Select

• Additional address(s) visited:

  Yes

  No

  N/A

  Unknown

• How many additional addresses were visited

• List additional address(s) visited:

• Survey pictures attached (attach all survey pictures here)

  Media

Loss Control Grading Exposures

• Property

  Select Exposure - Slight Exposure- Moderate Exposure- Severe Control- Acceptable Control -Unacceptable Not Evaluated

  • Exposure - Slight
  • Exposure- Moderate
  • Exposure- Severe
  • Control- Acceptable
  • Control -Unacceptable
  • Not Evaluated

• General Liability

  Select Exposure - Slight Exposure- Moderate Exposure- Severe Control- Acceptable Control -Unacceptable Not Evaluated

  • Exposure - Slight
  • Exposure- Moderate
  • Exposure- Severe
  • Control- Acceptable
  • Control -Unacceptable
  • Not Evaluated

• Workers' Compensation

  Select Exposure - Slight Exposure- Moderate Exposure- Severe Control- Acceptable Control -Unacceptable Not Evaluated

  • Exposure - Slight
  • Exposure- Moderate
  • Exposure- Severe
  • Control- Acceptable
  • Control -Unacceptable
  • Not Evaluated

• Commercial Auto

  Select Exposure - Slight Exposure- Moderate Exposure- Severe Control- Acceptable Control -Unacceptable Not Evaluated

  • Exposure - Slight
  • Exposure- Moderate
  • Exposure- Severe
  • Control- Acceptable
  • Control -Unacceptable
  • Not Evaluated

• Products Liability/Completed Operations

  Select Exposure - Slight Exposure- Moderate Exposure- Severe Control- Acceptable Control -Unacceptable Not Evaluated

  • Exposure - Slight
  • Exposure- Moderate
  • Exposure- Severe
  • Control- Acceptable
  • Control -Unacceptable
  • Not Evaluated

• Inland Marine

  Select Exposure - Slight Exposure- Moderate Exposure- Severe Control- Acceptable Control -Unacceptable Not Evaluated

  • Exposure - Slight
  • Exposure- Moderate
  • Exposure- Severe
  • Control- Acceptable
  • Control -Unacceptable
  • Not Evaluated

• Crime

  Select Exposure - Slight Exposure- Moderate Exposure- Severe Control- Acceptable Control -Unacceptable Not Evaluated

  • Exposure - Slight
  • Exposure- Moderate
  • Exposure- Severe
  • Control- Acceptable
  • Control -Unacceptable
  • Not Evaluated

• Management Commitment and Direction

  Acceptable

  Unacceptable

  Not available

• Loss History (If unacceptable (any single claim(s) >$10K), explain in the notes)

  Select This account shows an acceptable loss history This account shows an unacceptable loss history No loss history available

  • This account shows an acceptable loss history
  • This account shows an unacceptable loss history
  • No loss history available

• Loss Consultant Signature

  Sign

Location/Operation Recommendation(s) Written

• Address Related To Recommendations

Recommendation(s) Written

• Recommendation

  Select

• Mandatory or Advisory

  Mandatory

  Advisory

• Recommendation picture (attach picture(s) relevant to recommendation here)

  Media

• Review Risk Warranted

  Select Review Risk Needed - Unacceptable Account Review Risk Not Needed - Acceptable Account

  • Review Risk Needed - Unacceptable Account
  • Review Risk Not Needed - Acceptable Account

• Has the UW/Manager of this account been contacted

  Yes

  No

• Description of Operations:

• Does insured conduct any operations outside their normal realm of practice on a part-time or seasonal basis (explain in work performed in notes)

  Yes

  No

  N/A

  Unknown

• Type of work performed

  Select Asbestos Remediation Billing Services Carpentry Concrete Cutting Crane Operations Demolition Operations Electrical Install/Repair Excavation Operations Fire Sprinkler Install/Repair Flooring Install/Repair Framing-Construction Ground Irrigation System Install/Repair HVAC Install/Repair Landscaping Lawn Care Lead Remediation Life Safety Item Install/Repair Material Disposal Plumbing Install/Repair Property Management Roofing Operations Shipping Snow Removal Storage Units Trenching Operations Trucking/Logistics Other

  • Asbestos Remediation
  • Billing Services
  • Carpentry
  • Concrete Cutting
  • Crane Operations
  • Demolition Operations
  • Electrical Install/Repair
  • Excavation Operations
  • Fire Sprinkler Install/Repair
  • Flooring Install/Repair
  • Framing-Construction
  • Ground Irrigation System Install/Repair
  • HVAC Install/Repair
  • Landscaping
  • Lawn Care
  • Lead Remediation
  • Life Safety Item Install/Repair
  • Material Disposal
  • Plumbing Install/Repair
  • Property Management
  • Roofing Operations
  • Shipping
  • Snow Removal
  • Storage Units
  • Trenching Operations
  • Trucking/Logistics
  • Other

• How many snow plows does the insured have

• What is the estimated % of total revenue from snow removal

• Who does the insured/prospect complete snow removal for (check all that apply)

  Select

• Documented service agreements in place for work

  Yes

  No

  N/A

  Unknown

• How long has the insured been a Donegal policy holder

  Select 1-5 years 5.5-10 years 10.5- 15 years 15.5+ years Unknown Not a Donegal Policyholder- Prospect

  • 1-5 years
  • 5.5-10 years
  • 10.5- 15 years
  • 15.5+ years
  • Unknown
  • Not a Donegal Policyholder- Prospect

• Insured projected revenue (current year)

• Business hours

• Total number of employees:

• Full-Time:

• Part-Time (Year Round):

• Seasonal:

• Management/Ownership:

• Office/Clerical:

• Field:

• Sales:

• Warehouse/Production/Service:

• Percentage of work: Commercial

• Percentage of work: Residential

• Percentage of work: Industrial/Manufacturing

• Percentage of work: Shipping/Logistics

• Percentage of work: Food Preparation

• What states does the insured operate in:

  Select

• Documented business continuity plan in place

  Yes

  No

  N/A

  Unknown

Property

• Is the property LOB being evaluated

  Yes

  No

  N/A

  Unknown

• Building pictures attached (attach building pictures applicable to this location here)

  Media
• Address
  Address

• Location # as listed on policy

• Building # as listed on policy

• ITV calculated (attach replacement cost valuation to report)

  Yes

  No

  None Required

• Is the calculated building replacement cost more than 15% above or below the building limits stated in the policy?

  Yes

  No

  Unknown

• Diagram developed (attach diagram to report)

  Yes

  No

  None Required

• PML factor

  Low

  Moderate

  High

  None Required

• Is there a property maintenance program in place

  Yes

  No

  N/A

  Unknown

• How is the property maintenance being tracked

  Select

• The property was observed in the following condition- structural and housekeeping

  Like New Condition

  Good Condition

  Fair Condition

  Unacceptable Condition

• The building is identified as one or multiple of the following material types;

  Select ISO 1 - Frame ISO 2 - Joisted Masonry ISO 3 - Non-Combustible ISO 4 - Masonry Non-Combustible ISO 5 - Modified or Semi Fire Resistive ISO 6 - Fire Resistive

  • ISO 1 - Frame
  • ISO 2 - Joisted Masonry
  • ISO 3 - Non-Combustible
  • ISO 4 - Masonry Non-Combustible
  • ISO 5 - Modified or Semi Fire Resistive
  • ISO 6 - Fire Resistive

• Year the property was built

• Approximate square footage

• Property ownership

  Select Owned by Insured Leased by Insured Leased by Insured from Property Management LLC also operated by Insured.

  • Owned by Insured
  • Leased by Insured
  • Leased by Insured from Property Management LLC also operated by Insured.

• Property occupied by OTHER tenants outside of the insured

  Yes

  No

  N/A

  Unknown

• # of third party tenant(s) occupying property

• % of property occupied by third party tenant(s)

• Current lease/rental agreement in place with tenant(s) and property owner that includes hold harmless language

  Yes

  No

  N/A

  Unknown

• Tenant(s) furnish current certificate(s) of insurance with records kept by property owner

  Yes

  No

  N/A

  Unknown

• Building occupancy

  Select

• Roof type

  Select Gable Flat Pitched Curved Combo Other

  • Gable
  • Flat
  • Pitched
  • Curved
  • Combo
  • Other

• Roofing material

  Select Shingled - Architectural Painted Ribbed Metal Membrane - EPDM or PVC Built-Up (Hot Mopped) - w/Gravel Built-Up (Hot Mopped) - w/o Gravel Greenhouse Film (Plastic) Metal Tile/Shake Shingle - Impact Resistant Shingled - Wood Standing Seam Metal Sprayed Polyurethane Foam (SPF) Clay Tile Copper Roof Polycarbonate Roof Material

  • Shingled - Architectural
  • Painted Ribbed Metal
  • Membrane - EPDM or PVC
  • Built-Up (Hot Mopped) - w/Gravel
  • Built-Up (Hot Mopped) - w/o Gravel
  • Greenhouse Film (Plastic)
  • Metal Tile/Shake
  • Shingle - Impact Resistant
  • Shingled - Wood
  • Standing Seam Metal
  • Sprayed Polyurethane Foam (SPF)
  • Clay Tile
  • Copper Roof
  • Polycarbonate Roof Material

• Approximate roof age

  1- 10 Years

  10.5 - 18 Years

  18.5 -26 Years

  26.5 + Years

  Unknown

• Solar panels on roof

  Yes

  No

  N/A

  Unknown

• Roofing inspection program present

  Yes

  No

  N/A

  Unknown

• Number of years since last roof inspection conducted

• Any active roof leaks observed

  Yes

  No

  Unknown

• Property/equipment storage location(s) secured

  Yes

  No

  Unknown

• Security measures

  Select Surveillance Camera System Motion-Activated Security Well Lit Area Fenced/Gated Area Remote/secluded area Unknown

  • Surveillance Camera System
  • Motion-Activated Security
  • Well Lit Area
  • Fenced/Gated Area
  • Remote/secluded area
  • Unknown

• Surveillance camera system monitored by central station alarm company

  Yes

  No

  Unknown

• Is there any building on the policy that is vacant

  Yes

  No

  N/A

  Unknown

• Any significant updates to the HVAC, plumbing or electrical system in the last 5 years (explain update(s) in notes)

  Yes

  No

  N/A

  Unknown

• Any section of the building that is unheated (define section(s) in notes)

  Yes

  No

  N/A

  Unknown

• % of building unheated

• If applicable, fluid (water) piping in this area(s) equipped with thermal wrapping and/or additional freeze prevention measures

  Yes

  No

  N/A

  Unknown

• Was there an electrical review done by the LCC during this survey

  Yes

  No

  N/A

  Unknown

• Concerns identified by LCC during review (define concern(s) in notes)

  Yes

  No

  N/A

  Unknown

• Is the electrical system older than 30 years old

  Yes

  No

  N/A

  Unknown

• System reviewed by a licensed electrician within the last 1-3 yrs?

  Yes

  No

  N/A

  Unknown

• Life safety items found onsite

  Yes

  No

  N/A

  Unknown

• Life safety items include

  Select

• Documented maintenance program for life safety items

  Yes

  No

  N/A

  Unknown

• Controlled access to property

  Yes

  No

  N/A

  Unknown

• Controlled access measures

  Select

• Is there an alarm(s) present

  Yes

  No

  Unknown

• Alarm types

  Select Security Alarm w/ Central Station Monitoring Security Alarm w/o Central Station Monitoring Smoke Detection w/ Central Station Monitoring Smoke Detection w/o Central Station Monitoring Carbon Monoxide Detection w/ Central Station Monitoring Carbon Monoxide Detection w/o Central Station Monitoring Fire Alarm Pull Station w/ Central Station Monitoring Fire Alarm Pull Station w/o Central Station Monitoring Other (add to notes section)

  • Security Alarm w/ Central Station Monitoring
  • Security Alarm w/o Central Station Monitoring
  • Smoke Detection w/ Central Station Monitoring
  • Smoke Detection w/o Central Station Monitoring
  • Carbon Monoxide Detection w/ Central Station Monitoring
  • Carbon Monoxide Detection w/o Central Station Monitoring
  • Fire Alarm Pull Station w/ Central Station Monitoring
  • Fire Alarm Pull Station w/o Central Station Monitoring
  • Other (add to notes section)

• Alarm monitoring company

• "No Smoking" signage available where appropriate

  Yes

  No

  N/A

• Any noted risk exposures inside or outside of the property

  Yes

  No

  N/A

  Unknown

• Flammable liquid exposures

  Yes

  No

  N/A

  Unknown

• Quantity used/stored onsite

• Area(s) used/stored

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Storage configuration

  Select Flammable Storage Cabinet Non-Flammable Storage Cabinet Flammable Liquid Storage Room Open/Shelves

  • Flammable Storage Cabinet
  • Non-Flammable Storage Cabinet
  • Flammable Liquid Storage Room
  • Open/Shelves

• Aerosol exposure

  Yes

  No

  N/A

  Unknown

• Quantity used/stored onsite

• Area(s) used/stored

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Storage configuration

  Select Flammable Storage Cabinet Non-Flammable Storage Cabinet Flammable Liquid Storage Room Open/Shelves

  • Flammable Storage Cabinet
  • Non-Flammable Storage Cabinet
  • Flammable Liquid Storage Room
  • Open/Shelves

• Plastic exposure

  Yes

  No

  N/A

  Unknown

• Injection/extrusion operation(s) onsite

  Yes

  No

  N/A

  Unknown

• Quantity used/stored onsite

• Area(s) used/stored

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Storage configuration

  Select On Floor Stacked Pallets Rack Storage

  • On Floor
  • Stacked Pallets
  • Rack Storage

• Rubber exposure

  Yes

  No

  N/A

  Unknown

• Injection/extrusion operation(s) onsite

  Yes

  No

  N/A

  Unknown

• Quantity used/stored onsite

• Area(s) used/stored

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Storage configuration

  Select On Floor Stacked Pallets Rack Storage

  • On Floor
  • Stacked Pallets
  • Rack Storage

• Rolled paper exposure

  Yes

  No

  N/A

  Unknown

• Printing operation(s) onsite

  Yes

  No

  N/A

  Unknown

• Quantity of rolls used/stored onsite

• Area(s) used/stored

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Storage configuration

  Select On Floor Stacked Pallets Rack Storage

  • On Floor
  • Stacked Pallets
  • Rack Storage

• Hangered garment/textile exposure

  Yes

  No

  N/A

  Unknown

• Screen printing operation(s) onsite

  Yes

  No

  N/A

  Unknown

• Industrial laundry operation(s) onsite

  Yes

  No

  N/A

  Unknown

• Any stored garment(s)/textile(s) comprised of highly flammable synthetic fibers, untreated cotton, linen, or silk

  Yes

  No

  N/A

  Unknown

• % of stored garment(s)/textile(s) comprised of highly flammable synthetic fibers, untreated cotton, linen, or silk

• Area(s) used/stored

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Storage configuration

  Select On Floor - Boxed On Floor - Unboxed Stacked Pallets - Boxed Stacked Pallets - Unboxed Rack Storage - Boxed Rack Storage -Unboxed Hangered/Display Racks - Unboxed

  • On Floor - Boxed
  • On Floor - Unboxed
  • Stacked Pallets - Boxed
  • Stacked Pallets - Unboxed
  • Rack Storage - Boxed
  • Rack Storage -Unboxed
  • Hangered/Display Racks - Unboxed

• Habitational exposure operated by insured

  Yes

  No

  N/A

  Unknown

• Apartment/multi-unit residential exposure

  Yes

  No

  N/A

  Unknown

• # of residential units

• % of residential units currently occupied

• Residential units equipped with smoke detection device(s)

  Yes

  No

  N/A

  Unknown

• Power supply to smoke detection device(s)

  Select Hard Wired Battery

  • Hard Wired
  • Battery

• Who maintains battery(s) in smoke detection device(s)

  Select Property Manager Tenant(s)

  • Property Manager
  • Tenant(s)

• Residential units equipped with carbon monoxide (CO) detection device(s)

  Yes

  No

  N/A

  Unknown

• Power supply to carbon monoxide detection device(s)

  Select Hard Wired Battery

  • Hard Wired
  • Battery

• Who maintains battery(s) in carbon monoxide detection device(s)

  Select Property Manager Tenant(s)

  • Property Manager
  • Tenant(s)

• Property management performs routine inspection of residential units

  Yes

  No

  N/A

  Unknown

• Residential unit inspection frequency

  Select Daily Weekly Monthly Quarterly Semi-Annually Annually As needed

  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Semi-Annually
  • Annually
  • As needed

• Any student or subsidized housing

  Yes

  No

  N/A

  Unknown

• % of residential units occupied by student or unsubsidized tenants

• Residential units equipped with gas powered appliances

  Yes

  No

  N/A

  Unknown

• Barbecue grills allowed on balcony(s) or within 10ft of the structure

  Yes

  No

  N/A

  Unknown

• Tenant(s) permitted to burn candles or smoke in residential units

  Yes

  No

  N/A

  Unknown

• Hotel/motel exposure

  Yes

  No

  N/A

  Unknown

• # of rooms in property

• % of rooms occupied on a weekly basis (average)

• Rooms equipped with smoke detection device(s)

  Yes

  No

  N/A

  Unknown

• Power supply to smoke detection device(s)

  Select Hard Wired Battery

  • Hard Wired
  • Battery

• Who maintains battery(s) in smoke detection device(s)

  Select Property Manager Tenant(s)

  • Property Manager
  • Tenant(s)

• Rooms equipped with carbon monoxide (CO) detection device(s)

  Yes

  No

  N/A

  Unknown

• Power supply to carbon monoxide detection device(s)

  Select Hard Wired Battery

  • Hard Wired
  • Battery

• Who maintains battery(s) in carbon monoxide detection device(s)

  Select Property Manager Tenant(s)

  • Property Manager
  • Tenant(s)

• Property management performs routine inspection of rooms

  Yes

  No

  N/A

  Unknown

• Room inspection frequency

  Select Daily Weekly Monthly Quarterly Semi-Annually Annually As needed

  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Semi-Annually
  • Annually
  • As needed

• Rooms equipped with gas powered appliances

  Yes

  No

  N/A

  Unknown

• Barbecue grills allowed on balcony(s) or within 10ft of the structure

  Yes

  No

  N/A

  Unknown

• Tenant(s) permitted to burn candles or smoke in rooms

  Yes

  No

  N/A

  Unknown

• Commercial cooking exposure

  Yes

  No

  N/A

  Unknown

• Employees Servesafe certified

  Yes

  No

  Unknown

• Frying/oil operation(s) onsite

  Yes

  No

  N/A

  Unknown

• Fryer(s) separated from open flame(s) by minimum 16 inches or equipped with stainless steel/tempered glass baffle(s) at least 8 inches in height.

  Yes

  No

  N/A

  Unknown

• Cooking operations equipped with Ansul system

  Yes

  No

  Unknown

• Ansul system inspected by professional contractor in the last 6 months

  Yes

  No

  Unknown

• Location equipped with wet chemical (K-type) fire extinguisher(s)

  Yes

  No

  Unknown

• Cooking operation(s) equipped with hood/duct system vented to exterior of building

  Yes

  No

  N/A

  Unknown

• Hood/duct system cleaned by professional contractor in the last 6 months

  Yes

  No

  Unknown

• Hood/duct system equipped with "mesh" filters

  Yes

  No

  Unknown

• Painting/spraying exposure

  Yes

  No

  N/A

  Unknown

• Area(s) operations conducted

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Paint/spray booth(s) used

  Yes

  No

  N/A

  Unknown

• Number of booth(s)

• Booth type(s)

  Select 3-Sided Fully Enclosed

  • 3-Sided
  • Fully Enclosed

• Booth(s) constructed of non-combustible material(s)

  Yes

  No

  N/A

  Unknown

• Booth(s) equipped with approved lighting with no exposed electrical connections

  Yes

  No

  N/A

  Unknown

• Booth(s) equipped with mechanical exhaust vented to exterior of building

  Yes

  No

  N/A

  Unknown

• Spray guns(s) interlocked with mechanical exhaust system

  Yes

  No

  N/A

  Unknown

• Filters cleaned routinely

  Yes

  No

  Unknown

• Booth(s) equipped with Ansul system

  Yes

  No

  N/A

  Unknown

• Ansul system inspected professional contractor in the last 6 months

  Yes

  No

  Unknown

• Paint mixing conducted onsite

  Yes

  No

  N/A

  Unknown

• Grounding/bonding utilized

  Yes

  No

  N/A

  Unknown

• Mixing conducted in designated paint mixing room

  Yes

  No

  N/A

  Unknown

• Room equipped with approved automatic fire protection system & portable fire extinguisher

  Yes

  No

  N/A

  Unknown

• Room equipped with mechanical exhaust vented to exterior of building

  Yes

  No

  N/A

  Unknown

• Room equipped with spill containment system

  Yes

  No

  N/A

  Unknown

• Room equipped with approved lighting with no exposed electrical connections

  Yes

  No

  N/A

  Unknown

• Welding/hot work exposure

  Yes

  No

  N/A

  Unknown

• Area(s) welding/hot work operation conducted

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Designated location away from combustible/flammable material storage

  Yes

  No

  Unknown

• Hot work permits utilized

  Yes

  No

  N/A

  Unknown

• Fire watch w/fire extinguisher utilized

  Yes

  No

  N/A

  Unknown

• Oxygen cylinders stored >20ft from fuel gas cylinders/combustible materials or equipped with a 30-min fire wall

  Yes

  No

  N/A

  Unknown

• Rack storage in building

  Yes

  No

  N/A

  Unknown

• Area(s) rack storage utilized

  Select Office Warehouse/Storage Shop/Maintenance Production/Assembly Storefront/Showroom Cooking/Food Preparation

  • Office
  • Warehouse/Storage
  • Shop/Maintenance
  • Production/Assembly
  • Storefront/Showroom
  • Cooking/Food Preparation

• Average storage height (ft)

• Number of rows

• Shelving make-up

  Select Wire Mesh Wood Plank Solid Material Cantilever Horizontal Bar

  • Wire Mesh
  • Wood Plank
  • Solid Material
  • Cantilever
  • Horizontal Bar

• Racks equipped with in-rack fire suppression

  Yes

  No

  Unknown

• Fuel dispensing/pumping exposure

  Yes

  No

  N/A

  Unknown

• Fuel type

  Select Diesel Gasoline Propane Other

  • Diesel
  • Gasoline
  • Propane
  • Other

• Fuel storage tank(s) utilized

  Yes

  No

  N/A

  Unknown

• Number of tank(s)

• Tank(s) properly labeled to contents

  Yes

  No

  Unknown

• Tank storage location(s)

  Select Building Interior Building Exterior

  • Building Interior
  • Building Exterior

• Storage proximity to building(s)

  Select >25ft <25ft

  • >25ft
  • <25ft

• Stanchion/spill barricade system

  Yes

  No

  Unknown

• "No smoking" signage posted

  Yes

  No

  Unknown

• Fire extinguisher(s) accessible

  Yes

  No

  Unknown

• Fuel pumps equipped with emergency shut-off

  Yes

  No

  Unknown

• Idle pallet storage present

  Yes

  No

  N/A

  Unknown

• Type of pallet(s) stored

  Select Wood Plastic Other

  • Wood
  • Plastic
  • Other

• Pallet storage location

  Select Building Interior Building Exterior

  • Building Interior
  • Building Exterior

• Interior stored pile(s) do not exceed 6ft (wood) in height or 4 pallets total (plastic) with minimum 8ft spacing between piles

  Yes

  No

  N/A

  Unknown

• Exterior stored pile(s) >50ft from building(s)

  Yes

  No

  N/A

  Unknown

• Fire suppression sprinkler system present

  Yes

  No

  N/A

  Unknown

• % of the building sprinklered

• Maximum ceiling height of sprinklered building (ft)

• Documented fire suppression system impairment plan w/impairment checklist

  Yes

  No

  N/A

  Unknown

• Type of fire suppression system(s)

  Select Wet Dry Pre-Action Antifreeze Deluge

  • Wet
  • Dry
  • Pre-Action
  • Antifreeze
  • Deluge

• Number of system(s)

• Fire suppression system inspected by professional contractor in the last 6 months

  Yes

  No

  Unknown

• Most recent inspection report available for review (attach report to report)

  Yes

  No

  Unknown

• Any discrepancies outlined by inspector on report (outline discrepancies in the notes)

  Yes

  No

  Unknown

• Discrepancies addressed by contractor or plan in place to address

  Yes

  No

  Unknown

• Fire suppression system water source

  Select Municipal Water System Onsite Tower/Tank

  • Municipal Water System
  • Onsite Tower/Tank

• Supply capacity (gal)

• Supply water temperature controlled with low temperature alarm

  Yes

  No

  Unknown

• Temperature control monitored by central station alarm company

  Yes

  No

  Unknown

• Storage source equipped with low water level alarm

  Yes

  No

  Unknown

• Low water level monitored by central station alarm company

  Yes

  No

  Unknown

• System(s) hydraulically calculated with affixed legible design placard(s) present

  Yes

  No

  N/A

  Unknown

• Fire suppression system density requirements meets NFPA13 standard given commodities stored

  Yes

  No

  Unknown

• System(s) equipped with water flow alarm(s)

  Yes

  No

  Unknown

• Water flow alarm type

  Select Vane Pressure Unknown

  • Vane
  • Pressure
  • Unknown

• Water flow alarm(s) monitored by central station alarm company

  Yes

  No

  Unknown

• System(s) equipped with tamper alarm(s)

  Yes

  No

  Unknown

• Tamper alarm(s) monitored by central station alarm company

  Yes

  No

  Unknown

• Fire department connection (FDC) clearly marked, accessible, capped, and free of vandalism/tampering

  Yes

  No

  Unknown

• Fire suppression sprinkler temperature rating(s)

  Select Ordinary - (135-170) - Orange/Red Bulb Intermediate - (175-225) - Yellow/Green Bulb High - (250-300) - Blue Bulb Extra High - (325-375) - Purple Bulb Very Extra High - (400-475) - Black Bulb Ultra High - (500-575) - Black Bulb Ultra High - (650+) - Black Bulb Unknown

  • Ordinary - (135-170) - Orange/Red Bulb
  • Intermediate - (175-225) - Yellow/Green Bulb
  • High - (250-300) - Blue Bulb
  • Extra High - (325-375) - Purple Bulb
  • Very Extra High - (400-475) - Black Bulb
  • Ultra High - (500-575) - Black Bulb
  • Ultra High - (650+) - Black Bulb
  • Unknown

• Minimum 6 spare sprinkler heads (per type) available with wrench

  Select Yes No Unknown

  • Yes
  • No
  • Unknown

• Minimum 18-inch clearance from all sprinkler heads

  Yes

  No

  Unknown

• Accessible fire hydrant within 1000'

  Yes

  No

  Unknown

• Fire pump present

  Yes

  No

  N/A

  Unknown

• Number of fire pumps

• Fire pump type(s)

  Select Electric Diesel

  • Electric
  • Diesel

• Fire pump location

  Select Building Interior - Secured Pump Room Building Interior - Unsecured Open Space Building Exterior - Secured Pump House Building Exterior - Unsecured Open Space

  • Building Interior - Secured Pump Room
  • Building Interior - Unsecured Open Space
  • Building Exterior - Secured Pump House
  • Building Exterior - Unsecured Open Space

• Pump house temperature controlled with low temperature alarm

  Yes

  No

  Unknown

• Temperature control monitored by central station alarm company

  Yes

  No

  Unknown

• Fire pump affixed with rating placard

  Yes

  No

  Unknown

• Documented fire pump maintenance program

  Yes

  No

  Unknown

• Fire pump maintenance conducted by

  Select Internal Personnel 3rd Party Contractor Unknown

  • Internal Personnel
  • 3rd Party Contractor
  • Unknown

• Churn tests completed - weekly (diesel) / monthly (electric)

  Yes

  No

  Unknown

• Pump flow test(s) performed by professional contractor in last 12 months

  Yes

  No

  Unknown

• Pump alarm test(s) performed by professional contractor in the last 12 months

  Yes

  No

  Unknown

• Fire riser(s) equipped with a backflow preventer(s)

  Yes

  No

  N/A

  Unknown

• Main drain flow tested in the last 90 days

  Yes

  No

  Unknown

• Documented backflow preventer inspection conducted by qualified contractor within the last 12 months

  Yes

  No

  Unknown

• Any unique or special circumstances identified (explain in the notes)

  Yes

  No

  N/A

  Unknown

• Are you completing the GL LOB during this review

  Yes

  No

  N/A

  Unknown

• Do the insured's customers come onsite for any reasons

  Yes

  No

  N/A

  Unknown

• Any slip, trips and falls hazards found during the visit

  Yes

  No

  Unknown

• Life safety items found onsite

  Select Yes No N/A Unknown

  • Yes
  • No
  • N/A
  • Unknown

• Life safety items include

  Select

• Documented maintenance program for life safety items

  Yes

  No

  N/A

  Unknown

• Does the insured subcontract any operations out to 3rd party contractors

  Yes

  No

  N/A

  Unknown

• % of work being subcontracted

• Type of work subcontracted out

  Select Asbestos Remediation Billing Services Carpentry Concrete Cutting Crane Operations Demolition Operations Electrical Install/Repair Excavation Operations Fire Sprinkler Install/Repair Flooring Install/Repair Framing-Construction Ground Irrigation System Install/Repair HVAC Install/Repair Landscaping Lawn Care Lead Remediation Life Safety Item Install/Repair Material Disposal Plumbing Install/Repair Property Management Roofing Operations Shipping Snow Removal Storage Units Trenching Operations Trucking/Logistics Other

  • Asbestos Remediation
  • Billing Services
  • Carpentry
  • Concrete Cutting
  • Crane Operations
  • Demolition Operations
  • Electrical Install/Repair
  • Excavation Operations
  • Fire Sprinkler Install/Repair
  • Flooring Install/Repair
  • Framing-Construction
  • Ground Irrigation System Install/Repair
  • HVAC Install/Repair
  • Landscaping
  • Lawn Care
  • Lead Remediation
  • Life Safety Item Install/Repair
  • Material Disposal
  • Plumbing Install/Repair
  • Property Management
  • Roofing Operations
  • Shipping
  • Snow Removal
  • Storage Units
  • Trenching Operations
  • Trucking/Logistics
  • Other

• Documented written agreement(s) established with all 3rd party contractors

  Yes

  No

  Unknown

• Written agreement(s) include hold harmless clause

  Yes

  No

  Unknown

• Written agreement(s) name insured additional insured on 3rd party contract policy(s)

  Yes

  No

  Unknown

• Certificates of insurance (COI) obtained from all 3rd party contractors prior to start of work

  Yes

  No

  Unknown

• COI's tracking method

  Select

• Does the insured allow their 3rd party contractors to sub out their work to additional levels of contractors

  Yes

  No

  N/A

  Unknown

• % of work being subcontracted

• Type of work subcontracted out

  Select Asbestos Remediation Billing Services Carpentry Concrete Cutting Crane Operations Demolition Operations Electrical Install/Repair Excavation Operations Fire Sprinkler Install/Repair Flooring Install/Repair Framing-Construction Ground Irrigation System Install/Repair HVAC Install/Repair Landscaping Lawn Care Lead Remediation Life Safety Item Install/Repair Material Disposal Plumbing Install/Repair Property Management Roofing Operations Shipping Snow Removal Storage Units Trenching Operations Trucking/Logistics Other

  • Asbestos Remediation
  • Billing Services
  • Carpentry
  • Concrete Cutting
  • Crane Operations
  • Demolition Operations
  • Electrical Install/Repair
  • Excavation Operations
  • Fire Sprinkler Install/Repair
  • Flooring Install/Repair
  • Framing-Construction
  • Ground Irrigation System Install/Repair
  • HVAC Install/Repair
  • Landscaping
  • Lawn Care
  • Lead Remediation
  • Life Safety Item Install/Repair
  • Material Disposal
  • Plumbing Install/Repair
  • Property Management
  • Roofing Operations
  • Shipping
  • Snow Removal
  • Storage Units
  • Trenching Operations
  • Trucking/Logistics
  • Other

• Documented written agreement(s) established with additional level of contractors

  Yes

  No

  Unknown

• Written agreement(s) name insured additional insured on additional level contractor policy(s)

  Yes

  No

  Unknown

• Certificates of insurance (COI) obtained from all additional level contractors prior to start of work

  Yes

  No

  Unknown

• COI's tracking method

  Select

• Any unique or special circumstances identified (explain in the notes)

  Yes

  No

  N/A

  Unknown

Employee Practices: Workers Comp Review

• Is the Workers Comp or Employee Practices LOB being reviewed today

  Yes

  No

  N/A

  Unknown

• Employee recruitment practices

  Select Employee Referral Newspaper Social Media Union Temporary Agency Recruiter Government Program - H-2A Visa Government Program - H-2B Visa Other

  • Employee Referral
  • Newspaper
  • Social Media
  • Union
  • Temporary Agency
  • Recruiter
  • Government Program - H-2A Visa
  • Government Program - H-2B Visa
  • Other

• New hire orientation performed that outlines employee manual/handbook, safety topics, and additional information specific to employees' job

  Yes

  No

  Unknown

• Criminal background checks performed on new hires

  Yes

  No

  N/A

  Unknown

• Drug/alcohol screening a part of the insured employment practices

  Yes

  No

  N/A

  Unknown

• Drug/alcohol screening practices utilized

  Select Upon Hire Random Screening Program Reasonable Suspicion Post-Accident/Incident

  • Upon Hire
  • Random Screening Program
  • Reasonable Suspicion
  • Post-Accident/Incident

• Union representation

  Yes

  No

  N/A

  Unknown

• Represented employee(s)/department(s)

  Select Management/Ownership Office/Clerical Field Drivers Sales Warehouse/Production Estimators

  • Management/Ownership
  • Office/Clerical
  • Field
  • Drivers
  • Sales
  • Warehouse/Production
  • Estimators

• Benefits provided to employees

  Select Yes No No - Union Employees Covered by Union

  • Yes
  • No
  • No - Union Employees Covered by Union

• Benefits provided

  Select Medical Dental Vision Life Insurance Short-Term/Long-Term Disability 401K/IRA Profit Sharing/Bonus PTO Other Unknown

  • Medical
  • Dental
  • Vision
  • Life Insurance
  • Short-Term/Long-Term Disability
  • 401K/IRA
  • Profit Sharing/Bonus
  • PTO
  • Other
  • Unknown

• Claim reporting system present

  Yes

  No

  N/A

  Unknown

• Designated physician/clinic for injury treatment

  Yes

  No

  N/A

  Unknown

• Method of care

  Select Urgent Care Emergency Room Private Physician Other Unknown

  • Urgent Care
  • Emergency Room
  • Private Physician
  • Other
  • Unknown

• Documented return to work program

  Yes

  No

  Unknown

• Documented employee handbook with routine overview

  Yes

  No

  Unknown

• Documented safety & health manual with routine overview

  Select Yes No N/A - Safety Outlined in Employee Handbook N/A - Safety Outlined in Union Contracts Unknown

  • Yes
  • No
  • N/A - Safety Outlined in Employee Handbook
  • N/A - Safety Outlined in Union Contracts
  • Unknown

• Insured has identified employee responsible for safety/health program administration

  Yes

  No

  Unknown

• Safety/health training performed

  Select Yes No Unknown

  • Yes
  • No
  • Unknown

• Frequency of safety/health training

  Select Upon Hire Daily Weekly Monthly Annually

  • Upon Hire
  • Daily
  • Weekly
  • Monthly
  • Annually

• Insured has established multi-departmental safety committee

  Yes

  No

  N/A

  Unknown

• Frequency of safety committee meetings

  Select Daily Weekly Monthly Quarterly Semi-Annually Annually As needed

  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Semi-Annually
  • Annually
  • As needed

• Multi-departmental representation on safety team

  Yes

  No

  Unknown

• Documented first aid/CPR/AED training performed in the last 3 years

  Yes

  No

  N/A

  Unknown

• Employees trained in first aid/CPR/AED

  Select All Employees Various Employees Managers/Foremen - Only Safety Team Members - Only

  • All Employees
  • Various Employees
  • Managers/Foremen - Only
  • Safety Team Members - Only

• Personal protective equipment (PPE) utilized by employees

  Yes

  No

  N/A

  Unknown

• PPE hazard assessment(s) performed on work areas

  Yes

  No

  Unknown

• Documented PPE policy with routine overview

  Yes

  No

  Unknown

• Documented PPE training program

  Yes

  No

  Unknown

• Type of PPE utilized

  Select Eye Protection Head Protection Foot Protection Hand Protection Hearing Protection Respiratory Protection Lift Assist Items

  • Eye Protection
  • Head Protection
  • Foot Protection
  • Hand Protection
  • Hearing Protection
  • Respiratory Protection
  • Lift Assist Items

• Insured provides all necessary PPE to employee(s) or provides financial incentive for employees to provide their own with safety factor equal to or greater than employer provided item(s)

  Yes

  No

  Unknown

• Any specialized operational exposures (LOTO, confined space, fork truck, etc.)

  Yes

  No

  N/A

  Unknown

• Crystalline silica exposure

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include exposure to crystalline silica (explain type of work in notes)

• Silica air monitoring conducted

  Yes

  No

  Unknown

• Documented crystalline silica exposure control plan with annual review

  Select Yes No No - Below the Permissible Exposure Level

  • Yes
  • No
  • No - Below the Permissible Exposure Level

• Documented crystalline silica exposure training program

  Yes

  No

  Unknown

• Dust mitigation measures utilized

  Yes

  No

  Unknown

• Chemical exposure (explain details of exposure in notes)

  Yes

  No

  N/A

  Unknown

• Documented hazard communication program with annual review

  Yes

  No

  Unknown

• Documented hazard communication training program

  Yes

  No

  Unknown

• Safety data sheets (SDS) inventory accessible to all employees

  Yes

  No

  Unknown

• Secondary containers properly labeled to contents

  Yes

  No

  N/A

  Unknown

• Confined space entry operations

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include work in confined spaces (explain type of work in notes)

• Insured has inventoried confined spaces in their operations

  Yes

  No

  N/A

  Unknown

• Documented confined space operational plan with routine overview

  Yes

  No

  Unknown

• Documented confined training program including entrant, attendant, and rescue operations

  Yes

  No

  Unknown

• Confined space equipment (harnesses, lanyards, tripods, etc.) inspected prior to usage with process in place for quarantine of defective items for replacement or repair

  Yes

  No

  Unknown

• Powered industrial truck - fork truck operations

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• Documented operator training program with permitting

  Yes

  No

  Unknown

• Equipment inspected prior to usage with process in place for quarantine of defective items for replacement or repair

  Yes

  No

  Unknown

• Man lift/scissor lift operations

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• Documented operator training program with permitting

  Yes

  No

  Unknown

• Equipment inspected prior to usage with process in place for quarantine of defective items for replacement or repair

  Yes

  No

  Unknown

• Crane operations (explain details of exposure in notes)

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• Type of crane(s) utilized

  Select Overhead/Bridge Gantry Jib Vehicle Mounted

  • Overhead/Bridge
  • Gantry
  • Jib
  • Vehicle Mounted

• Documented operator training program with permitting

  Yes

  No

  Unknown

• Documented crane inspection program

  Yes

  No

  Unknown

• Crane(s) inspected to manufacturer specifications

  Select Yes No Unknown

  • Yes
  • No
  • Unknown

• Inspections performed by professional contractor

  Yes

  No

  Unknown

• Bloodbourne pathogens exposure (explain details of exposure in notes)

  Yes

  No

  N/A

  Unknown

• Documented exposure control plan with routine overview

  Yes

  No

  Unknown

• Documented employee training program

  Yes

  No

  Unknown

• Live electrical operations

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include live electrical work (explain type work in notes)

• Documented electrical safety plan

  Yes

  No

  Unknown

• Documented electrical safety training program

  Yes

  No

  Unknown

• High voltage work performed - including busbar or panel wiring

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of live electrical work includes high voltage exposure (explain type of work in notes)

• Overhead powerline work performed

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of live electrical work includes overhead powerline exposure (explain type of work in notes)

• Solar panel or solar grid work performed

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of live electrical work includes solar panel or solar grid work (explain type of work in notes)

• Non-conductive tools utilized

  Yes

  No

  Unknown

• Energy isolation - lock out/tag out operations

  Yes

  No

  N/A

  Unknown

• Documented LOTO program with routine overview

  Yes

  No

  Unknown

• Documented LOTO training program with periodic inspections

  Yes

  No

  Unknown

• Working from heights (scaffolding, ladders, roof work)

  Yes

  No

  N/A

  Unknown

• % of operations include working from heights (explain type of work in notes)

• Scaffolding utilized in operations

  Yes

  No

  N/A

  Unknown

• Documented scaffold usage training program

  Yes

  No

  Unknown

• Scaffolds inspected prior usage

  Yes

  No

  Unknown

• Average height of scaffolds used in operations (ft)

• Ladders utilized in operations

  Yes

  No

  N/A

  Unknown

• Documented ladder training program

  Yes

  No

  Unknown

• Ladders inspected prior to use

  Yes

  No

  Unknown

• Average height of ladder(s) used in operations (ft)

• Fall protection utilized

  Yes

  No

  N/A

  Unknown

• Documented fall protection plan with routine overview

  Yes

  No

  Unknown

• Documented fall protection training program

  Yes

  No

  Unknown

• Fall protection equipment (harnesses, lanyards, anchors, etc.) inspected prior to usage with process in place for quarantine of defective items for replacement or repair

  Yes

  No

  Unknown

• Roof work performed

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations are roof work (explain type of work performed in notes)

• Machine guarding exposure

  Yes

  No

  N/A

  Unknown

• Documented machine equipment safety guarding plan with routine overview

  Yes

  No

  Unknown

• Documented machine equipment safety training program

  Yes

  No

  Unknown

• Machine guarding measures such as fixed guards, light curtains, presence sensing devices, etc. inspected prior to usage with process in place for quarantine of defective items for replacement or repair.

  Yes

  No

  Unknown

• Ergonomic exposure (explain details of exposure in notes)

  Yes

  No

  N/A

  Unknown

• Ergonomic hazard assessment(s) performed on work area(s)

  Yes

  No

  Unknown

• Documented ergonomic policy with routine overview

  Yes

  No

  Unknown

• Documented ergonomic training program

  Yes

  No

  Unknown

• Processes in place such as job rotation, ergo tools, lift tables, etc. to help mitigate ergonomic hazards

  Yes

  No

  Unknown

• Noise exposure in excess of 85dBA @ 8hr TWA (explain details of exposure in notes)

  Yes

  No

  N/A

  Unknown

• Noise exposure hazard assessment(s) performed on work area(s)

  Yes

  No

  Unknown

• Documented hearing conservation program with annual review

  Yes

  No

  Unknown

• Documented hearing conservation training program

  Yes

  No

  Unknown

• Annual audiometric testing performed on affected employees

  Yes

  No

  Unknown

• Insured provides hearing protection to affected employees

  Yes

  No

  Unknown

• Trenching operations

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include trenching (explain type of work performed in notes)

• Average trench depth (ft)

• Documented trenching operational plan with routine overview

  Yes

  No

  Unknown

• Documented trenching operations training program

  Yes

  No

  Unknown

• Excavating operations

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include excavation (explain type of work performed in notes)

• Documented excavation operational plan with routine overview

  Yes

  No

  Unknown

• Documented excavation operations training program

  Yes

  No

  Unknown

• Severe temperature exposure

  Yes

  No

  N/A

  Unknown

• Type of severe temperature exposure

  Select Heat Cold

  • Heat
  • Cold

• Documented heat illness prevention plan with routine overview (Construction Only)

  Yes

  No

  N/A

  Unknown

• Documented temperature exposure training program

  Yes

  No

  Unknown

• Measures in place such as thermal clothing, frequent breaks, etc. to help mitigate hazards

  Yes

  No

  Unknown

• High traffic or multi-company construction exposure

  Yes

  No

  N/A

  Unknown

• Documented high traffic operation training program

  Yes

  No

  Unknown

• Hi-Viz clothing/equipment worn by employees working in high-traffic or multi-company operations

  Yes

  No

  Unknown

• Water/aquatic exposures

  Yes

  No

  N/A

  Unknown

• Documented water/aquatic exposure operational program with routine overview

  Yes

  No

  Unknown

• Documented water/aquatic exposure training program

  Yes

  No

  Unknown

• Personal floatation devices utilized by employees during water/aquatic operations

  Yes

  No

  Unknown

• Boats, jet skis, or unmotorized vessels (kayaks, canoe, etc.) utilized by employees during water/aquatic operations

  Yes

  No

  N/A

  Unknown

• Documented operator training performed

  Yes

  No

  Unknown

• Painting/spraying exposures

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• Employees wear respirators during painting/spraying operations

  Yes

  No

  N/A

  Unknown

• Documented respiratory protection program with routine overview

  Yes

  No

  N/A

  Unknown

• Documented respiratory protection training program

  Yes

  No

  N/A

  Unknown

• Employee(s) fit tested prior to respirator usage

  Yes

  No

  N/A

  Unknown

• Lead remediation exposure

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include lead remediation (explain type of work performed in notes)

• Lead exposure hazard assessment performed on work area(s)

  Yes

  No

  Unknown

• Documented lead exposure compliance plan with routine overview

  Yes

  No

  N/A

  Unknown

• Documented lead exposure training program

  Yes

  No

  N/A

  Unknown

• Employees wear respirators during remediation operations

  Yes

  No

  N/A

  Unknown

• Documented respiratory protection program with routine overview

  Yes

  No

  N/A

  Unknown

• Documented respiratory protection training program

  Yes

  No

  N/A

  Unknown

• Employee(s) fit tested prior to respirator usage

  Yes

  No

  N/A

  Unknown

• Asbestos remediation exposure

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include asbestos remediation (explain type of work performed in notes)

• Asbestos exposure hazard assessment performed on work area(s)

  Yes

  No

  N/A

  Unknown

• Documented asbestos exposure compliance plan with routine overview

  Yes

  No

  N/A

  Unknown

• Documented asbestos exposure training program

  Yes

  No

  N/A

  Unknown

• Employees wear respirators during remediation operations

  Yes

  No

  N/A

  Unknown

• Documented respiratory protection program with routine overview

  Yes

  No

  N/A

  Unknown

• Documented respiratory protection training program

  Yes

  No

  N/A

  Unknown

• Employee(s) fit tested prior to respirator usage

  Yes

  No

  N/A

  Unknown

• Demolition operations

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• % of operations include demolition (explain type of work performed in notes)

• Documented demolition operations plan with routine overview

  Yes

  No

  Unknown

• Documented demolition operations training program

  Yes

  No

  Unknown

• Demolition operations in excess of two (2) stories

  Yes

  No

  N/A

  Unknown

• Welding/hot work exposure

  Yes

  No

  No - Contracted to 3rd Party

  Unknown

• Designated location away from combustible/flammable material storage

  Yes

  No

  Unknown

• Hot work permits utilized

  Yes

  No

  N/A

  Unknown

• Fire watch w/ fire extinguisher utilized

  Yes

  No

  N/A

  Unknown

• Oxygen cylinders stored >20ft from fuel gas cylinders/combustible materials or equipped with a 30-min fire wall

  Yes

  No

  Unknown

• Welding/hot work conducted on galvanized steel material(s)

  Yes

  No

  N/A

  Unknown

• Welding/hot work area(s) equipped with exhaust ventilation that draws fumes away from employee(s)

  Yes

  No

  N/A

  Unknown

• Welding/hot work conducted on stainless steel material(s)

  Yes

  No

  N/A

  Unknown

• Welding/hot work area(s) equipped with exhaust ventilation that draws fumes away from employee(s)

  Yes

  No

  N/A

  Unknown

• Any unique or special circumstances identified (explain in the notes)

  Yes

  No

  N/A

  Unknown

• Is the Auto LOB being reviewed today

  Yes

  No

  N/A

  Unknown

• Fleet vehicle pictures (attach any obtainable fleet vehicle pictures here)

  Media

• Fleet vehicle summary included (optional)

  Yes

  No

  N/A

• Fleet vehicle management program in place

  Yes

  No

  N/A

  Unknown

• Fleet management program includes

  Select Driver Selection Criteria Vehicle Maintenance Accident Reporting MVR Review Unknown

  • Driver Selection Criteria
  • Vehicle Maintenance
  • Accident Reporting
  • MVR Review
  • Unknown

• Documented fleet vehicle maintenance program

  Yes

  No

  N/A

  Unknown

• How is it being tracked

  Select

• Fleet vehicle(s) serviced on a routine basis

  Yes

  No

  Unknown

• Frequency of service

  Select Daily Weekly Monthly Quarterly Semi-Annually Annually As needed

  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Semi-Annually
  • Annually
  • As needed

• Fleet vehicle(s) serviced by

  Select Onsite Mechanic Local Mechanic Dealer 3rd Party Owner of Vehicle(s) Unknown

  • Onsite Mechanic
  • Local Mechanic
  • Dealer
  • 3rd Party Owner of Vehicle(s)
  • Unknown

• Observed fleet vehicle(s) condition

  Good

  Fair

  Poor

  N/A

  Unknown

• Fleet vehicle storage configuration

  Select External Parking Lot/Driveway Internal Garage/Building Parking Structure Unknown

  • External Parking Lot/Driveway
  • Internal Garage/Building
  • Parking Structure
  • Unknown

• Fleet vehicle storage location equipped with security measures

  Yes

  No

  N/A

  Unknown

• Storage location security measures

  Select Surveillance Camera System Motion-Activated Security Well Lit Area Fenced/Gated Area Remote/secluded area Unknown

  • Surveillance Camera System
  • Motion-Activated Security
  • Well Lit Area
  • Fenced/Gated Area
  • Remote/secluded area
  • Unknown

• Fleet vehicle(s) equipped with tracking devices

  Yes

  No

  N/A

  Unknown

• Alerts monitored by

• Fleet vehicle(s) equipped with backup camera(s)

  Yes

  No

  N/A

  Unknown

• Fleet vehicle(s) equipped with dash camera(s)

  Yes

  No

  N/A

  Unknown

• Fleet vehicle(s) equipped with handsfree device or is there a documented "no cell phone use" policy

  Yes

  No

  N/A

  Unknown

• # of fleet vehicle operator(s)

• Any fleet vehicle operators under the age of 21

  Yes

  No

  Unknown

• # of fleet vehicle operators under the age of 21

• Driving record reviews conducted

  Yes

  No

  N/A

  Unknown

• Frequency of driving record reviews

  Select Upon Hire Annually Post Incident/Accident Other Unknown

  • Upon Hire
  • Annually
  • Post Incident/Accident
  • Other
  • Unknown

• Driving record reviews conducted by

  Insured

  Agency

  Insurance Carrier

• Drug/alcohol screening performed

  Yes

  No

  N/A

  Unknown

• Drug/alcohol screening practices utilized

  Select New Hire Random screening program Reasonable suspicion Post-accident/incident DOT required testing

  • New Hire
  • Random screening program
  • Reasonable suspicion
  • Post-accident/incident
  • DOT required testing

• Fleet vehicle on-the-job driver training or defensive driver training provided

  Yes

  No

  N/A

  Unknown

• Frequency of training

  Select Upon Hire Monthly Annually As Needed Unknown

  • Upon Hire
  • Monthly
  • Annually
  • As Needed
  • Unknown

• Personal vehicle(s) utilized for company business

  Yes

  No

  Unknown

• Fleet vehicle(s) utilized for personal use, such as moving, transporting, and hauling

  Yes

  No

  Yes - Risk Ownership Only

  N/A

  Unknown

• Documented personal usage policy

  Yes

  No

  N/A

  Unknown

• Seatbelt usage policy in place

  Yes

  No

  Unknown

• Employees allowed to take fleet vehicle(s) home after hours

  Yes

  No

  N/A

  Unknown

• # of fleet vehicle(s) that go home after hours

• Take home vehicle storage configuration

  Select External Parking Lot/Driveway Internal Garage/Building Parking Structure Unknown

  • External Parking Lot/Driveway
  • Internal Garage/Building
  • Parking Structure
  • Unknown

• Any unique or special circumstances identified (explain in the notes)

  Yes

  No

  N/A

  Unknown

DOT Findings

• Are you reviewing the DOT practices for this account

  Yes

  No

  N/A

  Unknown

• DOT #

• # of DOT vehicles are on the account

• # of DOT drivers

• Safer results indicate

  Select No Violations Found No Inspections Found Some Violations; however still below the nation's average Several violations that indicated a higher-than-normal nationwide average

  • No Violations Found
  • No Inspections Found
  • Some Violations; however still below the nation's average
  • Several violations that indicated a higher-than-normal nationwide average

• Leading cause(s) of violation(s)

  Select Unsafe Driving Missing Driver Fitness Card Vehicle Maintenance Concerns Unknown

  • Unsafe Driving
  • Missing Driver Fitness Card
  • Vehicle Maintenance Concerns
  • Unknown

Products

• Are you reviewing any products or completed operations during this review

  Yes

  No

  N/A

  Unknown

• Are you assessing a product exposure

  Yes

  No

  N/A

  Unknown

• Does the insured manufacture/process any food/beverage product(s) (describe past, present, or future product(s) in notes)

  Yes

  No

  N/A

  Unknown

• Documented Hazard Analysis and Critical Control Points (HAACP) certification measures in place

  Yes

  No

  N/A

  Unknown

• Quality control program in place

  Yes

  No

  N/A

  Unknown

• Documented quality control testing/inspection procedures in place

  Yes

  No

  N/A

  Unknown

• Documented quality control auditing procedures in place

  Yes

  No

  N/A

  Unknown

• Product recall program in place

  Yes

  No

  N/A

  Unknown

• Documented product recall determination measures in place

  Yes

  No

  N/A

  Unknown

• Documented procedure for product isolation/disposal

  Yes

  No

  N/A

  Unknown

• Documented procedure for customer/consumer notification

  Yes

  No

  N/A

  Unknown

• Documented procedure for product replenishment

  Yes

  No

  N/A

  Unknown

• Does the insured manufacture any product(s) (describe past, present, or future product(s) in notes)

  Yes

  No

  N/A

  Unknown

• Does the insured manufacture any product(s) for the medical industry (describe past, present, or future product(s) in notes)

  Yes

  No

  N/A

  Unknown

• Does the insured manufacture any product(s) for the aerospace industry (describe past, present, or future product(s) in notes)

  Yes

  No

  N/A

  Unknown

• Does the insured manufacture any product(s) for the defense industry (describe past, present, or future product(s) in notes)

  Yes

  No

  N/A

  Unknown

• Documented quality control program in place that outlines suitable testing, inspection, examination, and auditing procedures.

  Yes

  No

  N/A

  Unknown

• Documented quality control testing/inspection procedures in place

  Yes

  No

  N/A

  Unknown

• Documented quality control auditing procedures in place

  Yes

  No

  N/A

  Unknown

• Documented product recall program in place that outlines procedures for recall determination, product isolation/disposal, customer/consumer notification, and product replenishment measures.

  Yes

  No

  N/A

  Unknown

• Documented product recall determination measures in place

  Yes

  No

  N/A

  Unknown

• Documented procedure for product isolation/disposal

  Yes

  No

  N/A

  Unknown

• Documented procedure for customer/consumer notification

  Yes

  No

  N/A

  Unknown

• Documented procedure for product replenishment

  Yes

  No

  N/A

  Unknown

• Are you assessing a completed operation exposure

  Yes

  No

  N/A

  Unknown

• Does the insured provide a warranty or "guarantee" on completed operations (explain stipulations of warranty in the notes. Outline duration of warranty(s) and on what services provided)

  Yes

  No

  N/A

  Unknown

• Is there a qualified competent person on staff

  Yes

  No

  N/A

  Unknown

• Is there a piece(s) of machinery/equipment that would cause significant financial or operational strain on the business if it were damaged, inoperable, or otherwise compromised (describe machinery/equipment in notes)

  Yes

  No

  N/A

  Unknown

• Does the insured utilize any foreign product(s) in their operations that would cause significant financial or operational strain on the business if the product(s) was unavailable due to logistical, trade, and/or supply line concerns. (describe product(s) in notes)

  Yes

  No

  N/A

  Unknown

• Are there safety/ health warnings, labels, and/or brochures required for the product(s)/services provided by the insured

  Yes

  No

  N/A

  Unknown

• Are warnings, labels, and/or brochures affixed and/or authored by the insured

  Select Yes No No - All Items Provided by Product Supplier/Manufacturer N/A

  • Yes
  • No
  • No - All Items Provided by Product Supplier/Manufacturer
  • N/A

• Any unique or special circumstances identified (explain in the notes)

  Yes

  No

  N/A

  Unknown