Policyholder Risk Assessment (Part A)

• Client:

• Conducted on:

  Date

• Prepared by:

• Client representative(s) present during assessment:

Business Information

• Business operations:

• Operations include commercial new construction.

  < 50% new commercial construction

  > 50% new commercial construction

• Operations include commercial remodeling.

  < 50% commercial remodel

  > 50% commercial remodel

• Operations include commercial service/repair.

  < 50% commercial service repair

  > 50% commercial service repair

• Operations include residential new construction.

  < 50% residential new construction

  > 50% residential new construction

• Operations include residential remodeling.

  < 50% residential remodel

  > 50 % residential remodel

• Operations include residential service/repair.

  < 50% residential service/repair

  > 50% residential service/repair

• Equipment used by workers:

  Select Hand tools Basic power tools Ladders Scaffolds Forklifts Cranes Aerial lifts Scissor lifts Other

  • Hand tools
  • Basic power tools
  • Ladders
  • Scaffolds
  • Forklifts
  • Cranes
  • Aerial lifts
  • Scissor lifts
  • Other

• Other equipment used:

• Equipment new and/or maintained?

  Yes

  No

  N/A

• Does the company use sub-contractors?

  Yes

  No

• What percentage of work is done by sub-contractors?

  0% - 25%

  25% - 50%

  > 50%

• Certificates of insurance are obtained and verified.

  Yes

  No

  N/A

• Subcontractors are screened/pre-qualified for safety performance.

  Yes

  No

  N/A

• Subcontractors screening/pre-qualification efforts include:

  Select Past OSHA violations OSHA incidence rates Verify subcontractor safety program Reputation/past experience Other

  • Past OSHA violations
  • OSHA incidence rates
  • Verify subcontractor safety program
  • Reputation/past experience
  • Other

• Other subcontractor screening/pre-qualification efforts include:

• Radius of operations

  0-50 miles

  0-100miles

  State-wde

  In/out of state

• Out of state operations:

• Ownership change in the past year?

  Yes

  No

• Does this company manage any other businesses?

  Yes

  No

Employee screening

• How does the company find applicants?

  Select Advertising (newspaper, Craigslist, etc.) Walk-ins Employee Referals Union

  • Advertising (newspaper, Craigslist, etc.)
  • Walk-ins
  • Employee Referals
  • Union

• Written applications required.

  Yes

  No

  N/A

• Applications and/or written job descriptions list the essential functions of the job (climbing ladders, lifting and carrying up to 75 pounds, crawling).

  Yes

  No

  N/A

• Criminal background checks conducted.

  Yes

  No

  N/A

• Criminal checks performed:

  Select County records checked State records checked Federal records checked

  • County records checked
  • State records checked
  • Federal records checked

• Workers compensation background checks conducted.

  Yes

  No

  N/A

• Work references veriied.

  Yes

  No

  N/A

• Integrity testing conducted.

  Yes

  No

  N/A

• Pre-hire drug testing is conducted.

  Yes

  No

  N/A

• Post-accident drug testing is conducted.

  Yes

  No

  N/A

• Suspicion drug testing is conducted.

  Yes

  No

  N/A

• Random drug testing is conducted. If yes, explain how many are tested how often.

  Yes

  No

  N/A

• DOT drug testing guidelines are followed for CDL holders.

  Yes

  No

  N/A

• Drug testing conducted per project contract, such as government projects.

  Yes

  No

  N/A

• Post-offer/pre-placement physicals performed.

  Yes

  No

  N/A

• MVR checks conducted.

  Yes - on all employees

  Yes - on all drivers

  No MVR checks

Workforce

• Total number of employees:

• Number of unskilled laborers:

• Number of skilled (foremen, carpenters, jouneymen) craft workers:

• Number of full-time drivers:

• Number of mechanics:

• Number of office management and administration staff (sales, estimating, HR):

• Number of contract (1099) workers:

• Number of other workers (specify by job title):

• Company utilizes temporary and/or day labor.

  Yes

  No

• Labor is paid:

  Hourly

  Piece rate

  Salary

• Percentage of shifts worked that exceed 10 hours per day:

  0-25%

  26-50%

  51-75%

  76-100%

• Average annual turnover rate:

  0-25%

  26-50%

  51-75%

  76-100%

• Percent of employees who's primary language is not English:

  All EEs fluent in English.

  1-25%

  26-50%

  51-75%

  76-100%

• How are language barriers managed?

  Select Informally through bilingual co-workers Company documentation and training is bilingual Field supervision is bilingual. Safety coordinator is bilingual

  • Informally through bilingual co-workers
  • Company documentation and training is bilingual
  • Field supervision is bilingual.
  • Safety coordinator is bilingual

Employee Benefits

• Is health insurance offered to emloyees?

  Yes

  No

  N/A

• How soon are health insurance benefits available to employees?

  Immediatelty

  With 60 days

  Within 6 months

  Within 1 year

  Over 1 year

• What percentage of premium does the company pay for the employee?

  0-25%

  26-50%

  51-75%

  76-100%

• What percentage of workers participate in healthcare coverage?

  0-25%

  26-50%

  51-75%

  76-100%

• Does the company offer a wellness program?

  Yes

  No

  N/A

• Does the company offer an Employee Assistance Program (EAP)?

  Yes

  No

  N/A

Safety Coordinator

• Designated safety coordinator in place with documented roles and responsibilities.

  Yes

  No

  N/A

• Percentage of time safety coordinator commits to safety.

  0-25%

  26-50%

  51-75%

  76-100%

• Safety coordinator is in the field regularly to assess safety, correct unsafe conditions, assess/address needs for proper tools and PPE.

  Yes

  No

  N/A

• Safety coordinator is knowledgeable in field operations, hazard identification, applicable regulatory requirements, and applicable safety controls.

  Yes

  No

  N/A

• Safety coordinator has pursued professional development opportunities in the past year to improve technical expertise and effectiveness of safety efforts. If yes, list any training, seminars, or conferences attended.

  Yes

  No

  N/A

• Safety coordinator has identified loss trends using insurance carrier loss history reports or other loss data in the last year.

  Yes

  No

  N/A

• Written action plans based off of loss trends are developed and shared with management and/or safety committee for implementation.

  Yes

  No

  N/A

• Other comments regarding safety coordinator:

Safety Program - Safety Training

• New Hire Safety Training

  No safety training provided

  Informal/on-the-job training provided. No format, criteria, or records

  Formal new hire training provided via safety videos or live instruction. Training mirrors safety rules.

  Formal new hire training provided via safety videos or live instruction. Training mirrors safety rules. Competency demonstrate through written test or demonstration.

• Weekly toolbox talks documented.

  Yes

  No

  N/A

• Daily safety huddles/task-hazard-analysis conducted.<br>

  Yes

  No

  N/A

• Daily safety huddles/task-hazard analysis are documented and signed by crew.

  Yes

  No

  N/A

• Routine company-wide safety meetings/training conducted:

  Monthly

  2-4 times per year

  Annually

  Never

• OSHA 10-Hour training is provided.

  Yes

  No

  N/A

• OSHA 10-Hour training is provided to:

  Select Non-supervisory field employees Field supervisors/foremen Company-authorized operators Company-designated "competent persons" All company employees Safety coordinator

  • Non-supervisory field employees
  • Field supervisors/foremen
  • Company-authorized operators
  • Company-designated "competent persons"
  • All company employees
  • Safety coordinator

• OSHA 30-Hour training is provided.

  Yes

  No

  N/A

• OSHA 30-Hour training is provided to:

  Select Non-supervisory field employees Field supervisors/foremen Company-authorized operators Company-designated "competent persons" All company employees Safety coordinator

  • Non-supervisory field employees
  • Field supervisors/foremen
  • Company-authorized operators
  • Company-designated "competent persons"
  • All company employees
  • Safety coordinator

• Documented scaffold competent person training is provided.

  Yes

  No

  N/A

• Scaffold competent person training is provided to:

  Select Non-supervisory field employees Field supervisors/foremen Company-authorized operators Company-designated "competent persons" All company employees Safety coordinator

  • Non-supervisory field employees
  • Field supervisors/foremen
  • Company-authorized operators
  • Company-designated "competent persons"
  • All company employees
  • Safety coordinator

• Documented fall protection competent training is provided.

  Yes

  No

  N/A

• Fall protecton training is provided to:

  Select Non-supervisory field employees Field supervisors/foremen Company-authorized operators Company-designated "competent persons" All company employees Safety coordinator

  • Non-supervisory field employees
  • Field supervisors/foremen
  • Company-authorized operators
  • Company-designated "competent persons"
  • All company employees
  • Safety coordinator

• Documented excavation competent person training is provided.

  Yes

  No

  N/A

• Excavation competent person training is provided to:

  Select Non-supervisory field employees Field supervisors/foremen Company-authorized operators Company-designated "competent persons" All company employees Safety coordinator

  • Non-supervisory field employees
  • Field supervisors/foremen
  • Company-authorized operators
  • Company-designated "competent persons"
  • All company employees
  • Safety coordinator

• First aid training is provided.

  Yes

  No

  N/A

• First aid training is provided to:

  Select Non-supervisory field employees Field supervisors/foremen Company-authorized operators Company-designated "competent persons" All company employees Safety coordinator

  • Non-supervisory field employees
  • Field supervisors/foremen
  • Company-authorized operators
  • Company-designated "competent persons"
  • All company employees
  • Safety coordinator

• CPR training is provided.

  Yes

  No

  N/A

• CPR training is provided to:

  Select Non-supervisory field employees Field supervisors/foremen Company-authorized operators Company-designated "competent persons" All company employees Safety coordinator

  • Non-supervisory field employees
  • Field supervisors/foremen
  • Company-authorized operators
  • Company-designated "competent persons"
  • All company employees
  • Safety coordinator

• Documented forklift training is provided to company-authorized forklift operators.

  Yes

  No

  N/A

• Other safety training is provided. If yes, list topics.

  Yes

  No

  N/A

• Other comments regarding safety training:

Safety Program - Enforcement of Safety Rules and Safe Working Conditions

• Safety program includes a written safety rule enforcement policy.

  Yes

  No

  N/A

• Workplace safety inspections

  No inspections or process for enforcement.

  Irregular and undocumented inspections.

  Regular (at least weekly) inspections documented.

• Corrective actions are documented on inspection documents to verify completion.

  Yes

  No

  N/A

• Safety violations

  No enforcement efforts.

  Only verbal warnings have been issued in the past year.

  Written reprimands have been issued for safety violations in the past year.

  Suspensions and/or terminations have been issued in the past year for safety violations.

Safety Program - Safety Rules

• Safety rules are:

  No safety rules

  Generic safety rules. Too vague to be effective or enforcable.

  Canned or outdated rules. Rules may not apply to operations or are too extensive to be effective.

  Operation/hazard-specific rules. Rules align with applicable federal safety standards.

• Rules are reviewed and updated annually. Rules are dated to confirm last review/revision.

  Yes

  No

  N/A

• Employees received training on rules updated over the past year.

  Yes

  No

  N/A

• Other comments regarding safety rules:

Safety Program - Claims Management

• Formal claims management procedure in place.

  Yes

  No

  N/A

• Claims procedure is company-specific (lists designated medical providers, policy number, claim reporting instructions)

  Yes

  No

  N/A

• New hires are informed in writing of company's designated medical providers.

  Yes

  No

  N/A

• Injured workers are informed in writing of company's designated medical providers.

  Yes

  No

  N/A

• Other comments regarding claims management:

Accident Investigation

• Accident investigations are documented.

  Yes

  No

  N/A

• Accidents are investigated by:

  Select Direct supervisor Safety coordinator Superintendent or project manager Top management of company

  • Direct supervisor
  • Safety coordinator
  • Superintendent or project manager
  • Top management of company

• Investigations identify contributing factors.

  Yes

  No

  N/A

• Investigations identify root causes.

  Yes

  No

  N/A

• Findings have stimulated changes in training, tools, processes, safety rules, or enforcement in the past year. If yes, provide specific example.

  Yes

  No

  N/A

• Injured worker completes accident statement outlining event and injuries incurred.

  Yes

  No

  N/A

• Other comments regarding accident investigation.

Return-to-Work

• Return-to-work implementation.

  No RTW offered

  No formal RTW policy. RTW may be offered informally case-by-case.

  Formal RTW policy. Rule 6 letters used as needed.

Evaluation Signature and Date

• Evaluator's signature:

  Sign