Loss Control Survey Report - Multi Peril - duplicate

• INSURANCE COMPANY

• INSURANCE AGENCY

• POLICY NUMBER

• EXPIRATION DATE

• POLICY HOLDER

• CORPORATE ADDRESS

• LOCATIONS SURVEYED

• CONTACT PERSON

• SURVEY DATE

• “Our survey of operations is for underwriting purposes and to assist with loss control activities. No responsibility is assumed for the discovery and elimination of hazards which could possibly cause accidents or damage at any facility that is surveyed. Compliance with any recommendations in no way guarantees the fulfillment of obligations as may be required by any local, state or federal laws.”
  
  

OPINION OF RISK

• Considered Above Average, Average or Below Average for class?

  Average

  Above Average

  Below Average

• Detail:

LOSS ANALYSIS

• Provide detail by year and coverage line

• Detail:

GENERAL INFORMATION & MANAGEMENT ASSESSMENT

• Describe ownership, involvement, onsite management, years of experience, attitude toward loss control, other business interests

• Detail:

DESCRIPTION OF OPERATIONS

• Detail the account's operations, process flow, customers, delivery, industry, raw materials, processes, departments, quality control, etc.

• Detail:

GENERAL LIABILITY

• General Liability Narrative

• Product Liability Narrative

PROPERTY

• Construction Type & Detail, Stories, Age, Square Footage, Perimeter

• Cost/Coverage $ / Square Foot

• PML / Amount Subject

• Private Protection

• Fire Detection/Notification

• Business Interruption

• ISO Public Protection Rating

• Hydrants and Distance

• Building Exposures w/in 100'

• Building Condition and Updates

• Crime Exposure

• Property Narrative

WORKERS’ COMPENSATION

• Annual Payroll

• Number of Employees

• Classification / Breakdown

• Employee Leasing, Temporary or Volunteer

  Yes

  No

  N/A

• Unionized

  Yes

  No

  N/A

• Turnover

• Subcontractors

  Yes

  No

  N/A

• Subcontractor controls

  Yes

  No

  N/A

• See Recommendation

• Pre-placement Physicals Examinations

  Yes

  No

  N/A

• Substance Abuse Policies

  Yes

  No

  N/A

• Workers' Compensation Exposures/Controls

AUTO/FLEET

• Number of vehicles, make/model, age, storage, use, drivers, controls

• Detail:

LOSS CONTROL PROGRAMMING

• Describe any safety / loss control programs, procedures, internal auditing, training, orientation, RTW, PPE, accident investigation. Include any specific coverage line information

• Detail:

RECOMMENDATIONS

• Recommendation

PHOTOGRAPHS

• Add Photograph

  Media