PALC Template SCH04 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

• Nature of Business

• Website

Description of Operations

• Number of Locations?

Operations Subcontracted

• Food Service

• Facilities/Maintenance/Grounds

• Transportation

Maintenance workers Responsible for

• Carpentry

• Grounds Keeping

• Plumbing

• Snow Removal

• Herbicide/Pesticide Application

• Electrical Work

• Painting

• Working @ Heights >4ft

• Excavation

Does School District Operate

• Bucket Truck

• ATV ( Including Gator/Mule)

• Water Treatment Facility

• Swimming Pool

• Excavator/ Back Hoe (includes tractor with back hoe attachment)

• Scissor/JLG Lift

• Gun/ Archery Range

• Does the insured own/operate aircraft?

  YES

  NO

• Any USL&H Exposure?

  YES

  NO

• Are there student work programs? (College Question)

  Yes

  No

  N/A

• Boat Operations

• Farms

• Other

• Foreign or out of state travel of faculty or staff?<br>

  YES

  NO

• Do Faculty/Staff/Administration actively participate in sports or athletic club activities?

  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 control measures that are in place to reduce potential injuries)

• Exposures/Controls

• 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)

• Who Provides Bus Transportation

  School District

  Outside Contractor

• 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/ Buses

• # 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

• Done on a regular basis?

  Yes

  No

  N/A

• 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

• Hazard Communication/GHS Lab Safety

  Yes

  No

  N/A

• Powered Industrial Truck

  Yes

  No

  N/A

• Lockout/Tagout

  Yes

  No

  N/A

• Confined Space

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Machine Guarding

  Yes

  No

  N/A

• Cranes/Hoists/Rigging Operations

  Yes

  No

  N/A

• Ergonomics/Material Handling

  Yes

  No

  N/A

• Loading Dock Safety

  Yes

  No

  N/A

• Fire Safety

  Yes

  No

  N/A

• Welding/Cutting/Brazing

  Yes

  No

  N/A

• Tools-Hand/Power

  Yes

  No

  N/A

• Electrical

  Yes

  No

  N/A

• Combustible Dust

  Yes

  No

  N/A

• flammables

  Yes

  No

  N/A

• Bloodborne Pathogens

  Yes

  No

  N/A

• Crossing Guard/ traffic monitors

  Yes

  No

  N/A

• Respiratory Protection

  Yes

  No

• Medical Evaluations

  Yes

  No

  N/A

• Fit testing

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Emergency Preparedness

  Yes

  No

  N/A

• Evacuation Plans

  Yes

  No

  N/A

• Workplace Violence/ Active Shooter Drills

  Yes

  No

  N/A

• Wellness Program Initiatives

  Yes

  No

  N/A

• Other safety Training

Safety Committee

• SC Established?

  Yes

  No

  N/A

• PA Certified

• Meeting Date/Time

• Does business manager or superintendent sit on committee?

Regulatory Compliance Review

• OSHA (if private)

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

• 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

  Select Unfavorable Average Above Average

  • Unfavorable
  • Average
  • Above Average

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