Information
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Account
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Is this a prospect survey?
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Visit Date
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Effective Date
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Address
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Contact Name & Title
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Contact Email Address
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Contact Phone#
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Contact Fax#
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Prepared by
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Underwriter
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Agency
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Agent
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Agent Email
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Website
Description of Operations
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Number of Campus Locations?
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Number of Program Extension Location/ Types not on site)
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HOME HEALTH SERVICES
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PHYSICIAN OFFICES
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PT/OT OFFICES
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Does the insured own/operate aircraft?
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Any USL&H Exposure?
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Foreign Travel?<br>
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Unionized labor force?
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What unions are involved
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Contract End Dates
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Total # of Employees
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# of FT
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# of PT
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# of Volunteers
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# of Temps
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Comments: (Seasonal Employees?; Use of temp to hire)
WC Class Code Description
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Class Code#
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Description
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Estimated Payroll
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# of Employees
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Employees over 65 years of age
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Class Code#
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Description
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Estimated Payroll
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# of Employees
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Employees over 65 years of age
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Class Code#
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Description
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Estimated Payroll
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# of Employees
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Employees over 65 years of age
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Class Code#
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Description
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Estimated Payroll
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# of Employees
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Employees over 65 years of age
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Class Code#
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Description
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Estimated Payroll
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# of Employees
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Employees over 65 years of age
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Comments/Findings
Human Resource Practices
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Application
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Interview
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References Checked
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Criminal Background Checked (Act 34 or FBI)
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Physical Exam
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Drug and Alcohol testing
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Post job offer (pre-employment)
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Post Incident
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Random
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For Cause
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Urine
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Oral Fluid
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Hair
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Blood
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Comments:
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Are Benefits Provided
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Turnover %?
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Does the insured employe non-English speaking employees?
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Formal Orientation
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What is supervisor's role in orienting new employees?
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Shadowing or Buddy System
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General staff experience level
Return to Work Program
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Written RTW Program
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Are employees brought back to work with restrictions after a work-related injury?
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Is someone assigned the responsibility to coordinate RTW?
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What types of modified duty jobs are available?
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Anybody currently on Light Duty?
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Any reasons why modified duty cannot be accommodated?
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Is modified duty part of the Union Contract?
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Are full wages paid to employees who are working light duty?
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Is there an allowable period of time in which an employee can be on modified duty?
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Does company currently post a panel? Acknowledgement forms signed (time of hire & post injury)
Exposures & Controls (Briefly describe the causes of injuries, exposures and/or unusual exposures along with the controls in place to reduce the potential for injury)
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Exposures/Controls
Healthcare
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# of Licensed "skilled" beds
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# of Licensed "assisted living" beds
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# of Licensed " Independent Living" beds
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Lifting Protocols
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Transfer Protocols
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1 mechanical lift available for every 8-10 residents identified as needing a lift
Safe Patient Handling Devices
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# of full lifts
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# of sit to stand lifts
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# of friction reducing devices
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# of stand aids
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Comments
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CNA Registration
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Board Certified Nurses
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TB Tests
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Hepatitis B Offered
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Titer Tests Completed after Hep B Series
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Universal Precautions/ Infection Control
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Safety Engineered Sharps Used
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Agency/Pool Staff Used? (If so how Many)
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Census & FTE- Address if lower than average
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Noise Testing
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Audiometric Exams
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Air/IAQ Testing
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Any Known buildings that have asbestos?
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Asbestos Policy ( Labeling, Non-disturbance, abatement, training)
Fleet Exposures (Note: UW or Agent may already have information; make/model not necessary)
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Does the Insured have fleet exposure?
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Cars
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# Used
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Radius
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# of Drivers
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Driven by whom?
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Small Trucks/SUV
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# Used
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Radius
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# of Drivers
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Driven by whom?
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Vans
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# Used
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Radius
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# of Drivers
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Driven by whom?
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CDL Vehicles
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# Used
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Radius
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# of Drivers
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Driven by whom?
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Other
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# Used
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Radius
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# of Drivers
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Driven by whom?
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Out of state or foreign travel?
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Do employees use personal car to conduct company business?
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Do employees operate motorized cycles while performing company business? ( do they take motorcycles in on trade?)
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Is group transportation provided?
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Written seat belt policy in place?
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Who is responsible for vehicle maintenance?
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Are licenses checked?
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Are Motor Vehicle Record Checks Completed
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Completed for new hires
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Done on a regular basis?
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Driver safety activities
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Safety Initiatives/Activities
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Top Management Support?
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Assignment of responsibility?
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Accident Investigation
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Policy/Procedures
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Investigation Form & Employee Statement Form?
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Training Conducted
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Hazard Inspections
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Frequency Conducted
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Types of Inspections
OSHA Requirements/ Company Specific Safety Activities
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Hazard Communication/GHS
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Powered Industrial Truck
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Lockout/Tagout
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Confined Space
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Fall Protection
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Machine Guarding
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Ergonomics/Material Handling
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Loading Dock Safety
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Fire Safety
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Electrical
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Combustible Dust
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flammables
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Bloodborne Pathogens
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Hearing Protection
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Pets/ Animal Safety
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Client Home Assessments (if applicable)
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Emergency Preparedness
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Evacuation Plans
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Workplace Violence/ Active Shooter
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Crisis Prevention Intervention/ Therapeutic Crisis Intervention
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Restraint Policy
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Surveillance Cameras
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Hallways
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Common Areas
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Other
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Wellness Program Initiatives
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Other safety Training
Safety Committee
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SC Established?
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PA Certified
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Meeting Date/Time
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Does top management sit on committee?
Regulatory Compliance Review
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OSHA
PPE Requirements
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Eye/Face Protection
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Do safety glasses have side shields and meet ANSI Z87.1 standards? (prescriptive & non-prescriptive lenses)
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Written policy in place that requires use of safety glasses?
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High visibility clothing for lot attendants?
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Hearing Protection
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Protective Footwear
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Hard Hat
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Hand/ARM
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Protective Clothing
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Has a PPE Hazard Assessment Been Completed?
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Comments
Comments on Previous Large Losses
Were there any changes in safety activities that have or will have an impact on past or future losses?
Specific UW Questions
Client service needs
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Loss Control
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LC Letter Distribution
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other service requests
Recommendations (Critical and/or Risk Improvement) *Completion of separate loss control recommendation form required to be given to Underwriter
Overall Opinion of Risk (Provide a brief description regarding opinion of risk selection)
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What is your overall opinion of risk
- Unfavorable
- Average
- Above Average
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