PALC Template HomeHlth06 V2

• Account

• Is this a prospect survey?

  Yes

  No

• Visit Date

  Date

• Effective Date

  Date

• Address

• Contact Name & Title

• Contact Email Address

• Contact Phone#

• Contact Fax#

• Prepared by

• Underwriter

• Agency

• Agent

• Agent Email

• Website

Description of Operations

• Number of office Locations?

• Number of beds per location?

• Number of shared senior living locations? (agency purchases homes and residents live there independently-agency provides services)

• Foreign Travel?<br>

  YES

  NO

• Unionized labor force?

  YES

  NO

• What unions are involved

• Contract End Dates

• Total # of Employees

• # of FT

• # of PT

• # of Volunteers

• # of Temps

• Comments: (Seasonal Employees?; Use of temp to hire)

WC Class Code Description

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Employees over 65 years of age

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Employees over 65 years of age

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Employees over 65 years of age

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Employees over 65 years of age

• Class Code#

• Description

• Estimated Payroll

• # of Employees

• Employees over 65 years of age

• Comments/Findings

Human Resource Practices

• Application

  Yes

  No

  N/A

• Interview

  Yes

  No

  N/A

• References Checked

  Yes

  No

  N/A

• Criminal Background Checked (Act 34 or FBI)

  Yes

  No

  N/A

• Physical Exam

  Yes

  No

  N/A

• Drug and Alcohol testing

  Yes

  No

  N/A

• Post job offer (pre-employment)

• Post Incident

• Random

• For Cause

• Urine

• Oral Fluid

• Hair

• Blood

• Comments:

• Are Benefits Provided

  Yes

  No

  N/A

• Turnover %?

• Does the insured employe non-English speaking employees?

  YES

  NO

• Formal Orientation

  Yes

  No

  N/A

• What is supervisor's role in orienting new employees?

• Shadowing or Buddy System

  Yes

  No

  N/A

• General staff experience level

Return to Work Program

• Written RTW Program

  Yes

  No

  N/A

• Are employees brought back to work with restrictions after a work-related injury?

  Yes

  No

  N/A

• Is someone assigned the responsibility to coordinate RTW?

  Yes

  No

  N/A

• What types of modified duty jobs are available?

• Anybody currently on Light Duty?

  Yes

  No

  N/A

• Any reasons why modified duty cannot be accommodated?

  YES

  NO

• Is modified duty part of the Union Contract?

  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

• Does company currently post a panel? Acknowledgement forms signed (time of hire & post injury)

  Yes

  No

  N/A

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)

• Exposures/Controls

Healthcare

• Lifting Protocols

  Yes

  No

  N/A

• Transfer Protocols

  Yes

  No

  N/A

• 1 mechanical lift available for every 8-10 residents identified as needing a lift

  Yes

  No

  N/A

Safe Patient Handling Mobility Devices

• # of full lifts

• # of sit to stand lifts

• # of friction reducing devices

• # of stand aids

• Comments

• Personal Care Attendants

  Yes

  No

  N/A

• CNA Registration

  Yes

  No

  N/A

• Board Certified Nurses

  Yes

  No

  N/A

• TB Tests

  Yes

  No

  N/A

• Hepatitis B Offered

  Yes

  No

  N/A

• Titer Tests Completed after Hep B Series

  Yes

  No

  N/A

• Universal Precautions/ Infection Control

  Yes

  No

  N/A

• Safety Engineered Sharps Used

  Yes

  No

  N/A

• Latex Allergy Protocols

  Yes

  No

  N/A

• Agency/Pool Staff Used? (If so how Many)

  Yes

  No

  N/A

• Census & FTE- Address if lower than average

• Noise Testing

  Yes

  No

  N/A

• Audiometric Exams

  Yes

  No

  N/A

• Air/IAQ Testing

  Yes

  No

  N/A

• Any Known buildings that have asbestos?

  YES

  NO

• Asbestos Policy ( Labeling, Non-disturbance, abatement, training)

Fleet Exposures (Note: UW or Agent may already have information; make/model not necessary)

• 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?

• Out of state or foreign travel?

  YES

  NO

• Do employees use personal car to conduct company business?

  YES

  NO

• Do employees operate motorized cycles while performing company business? ( do they take motorcycles in on trade?)

  YES

  NO

• Is group transportation provided?

  YES

  NO

• Written seat belt policy in place?

  Yes

  No

  N/A

• Who is responsible for vehicle maintenance?

• Are licenses checked?

  Yes

  No

  N/A

• Are Motor Vehicle Record Checks Completed

• Completed for new hires

  Yes

  No

  N/A

• Driving to more than one client location in day or run errands

• Only drive to one client/location a day

• Done on a regular basis?

  Yes

  No

  N/A

• Driving to more than one client location in day or run errands

• Only drive to one client/location a day

• Driver safety activities

Safety Initiatives/Activities

• Top Management Support?

  Yes

  No

  N/A

• Assignment of responsibility?

  Yes

  No

  N/A

• Accident Investigation

  Yes

  No

  N/A

• Policy/Procedures

• Investigation Form & Employee Statement Form?

  Yes

  No

  N/A

• Training Conducted

  Yes

  No

  N/A

• Hazard Inspections

  Yes

  No

  N/A

• Frequency Conducted

• Types of Inspections

OSHA Requirements/ Company Specific Safety Activities

• Client Home Assessments

  Yes

  No

  N/A

• Ergonomics/ Safe Patient Handling

  Yes

  No

  N/A

• Slip Trip Fall Awareness

  Yes

  No

  N/A

• Aggressive Client Behavior

  Yes

  No

  N/A

• Bloodborne Pathogens

  Yes

  No

  N/A

• Emergency Preparedness

  Yes

  No

  N/A

• Pets/ Animal Safety

  Yes

  No

  N/A

• Hazard Communication/GHS

  Yes

  No

  N/A

• Respiratory Protection

  Yes

  No

  N/A

• Fire Safety

  Yes

  No

  N/A

• Electrical

  Yes

  No

  N/A

• Wellness Program Initiatives

  Yes

  No

  N/A

• Other safety Training

• Weapon Policy?

  Yes

  No

  N/A

• Employee Violence/ Active Shooter

  Yes

  No

  N/A

• Surveillance Cameras

  Yes

  No

  N/A

• Hallways

• Common Areas

Safety Committee

• SC Established?

  Yes

  No

  N/A

• PA Certified

• Meeting Date/Time

• Does top management sit on committee?

Regulatory Compliance Review

• OSHA

PPE Requirements

• Eye/Face Protection

• Do safety glasses have side shields and meet ANSI Z87.1 standards? (prescriptive & non-prescriptive lenses)

  Yes

  No

  N/A

• Written policy in place that requires use of safety glasses?

  Yes

  No

  N/A

• Hearing Protection

• Protective Footwear

• Hard Hat

• Respiratory Protection

• Medical Evaluations Completed

• Fit Testing

• Hand/ARM

• Protective Clothing

• Has a PPE Hazard Assessment Been Completed?

  Yes

  No

  N/A

• 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

• Loss Control

• LC Letter Distribution

• 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)

• What is your overall opinion of risk

  Unfavorable

  Average

  Above Average

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