Risk Survey

• Facility

• Address

• Survey Type

• Survey Date

  Date

• Consultant

Site Contact

• Name

• Phone

• Cell

• Email

• Attachments located at end of the Survey Report

• Air Pollution Control

  +

  +/-

  -

  NA

• Emergency Action Planning

  +

  +/-

  -

  NA

• Hazardous Waste

  +

  +/-

  -

  NA

• Spill Prevention

  +

  +/-

  -

  NA

• Stormwater

  +

  +/-

  -

  NA

• Abrasive Blasting

  +

  +/-

  -

  NA

• Abrasive Grinding

  +

  +/-

  -

  NA

• Air Contaminants

  +

  +/-

  -

  NA

• Aisles & Passageways

  +

  +/-

  -

  NA

• Asbestos

  +

  +/-

  -

  NA

• Bloodborne Pathogens

  +

  +/-

  -

  NA

• Compressed Air, Use of

  +

  +/-

  -

  NA

• Compressed Gas Cylinders

  +

  +/-

  -

  NA

• Confined Spaces

  +

  +/-

  -

  NA

• Cranes, Hoists, & Derricks

  +

  +/-

  -

  NA

• Dockboards

  +

  +/-

  -

  NA

• Electrical

  +

  +/-

  -

  NA

• Emergency Action Plans

  +

  +/-

  -

  NA

• Emergency Response

  +

  +/-

  -

  NA

• Ergonomics

  +

  +/-

  -

  NA

• Eye & Face Protection

  +

  +/-

  -

  NA

• Eyewash/Drench Shower

  +

  +/-

  -

  NA

• Fall Protection

  +

  +/-

  -

  NA

• Fire Protection

  +

  +/-

  -

  NA

• Flammable Liquids

  +

  +/-

  -

  NA

• Floors

  +

  +/-

  -

  NA

• Hand & Power Tools

  +

  +/-

  -

  NA

• Hazard Communication

  +

  +/-

  -

  NA

• Hazardous Energy (Lockout/Tagout)

  +

  +/-

  -

  NA

• HAZWOPER

  +

  +/-

  -

  NA

• Ladders

  +

  +/-

  -

  NA

• Marking, Placards, & Labels

  +

  +/-

  -

  NA

• Medical Services & First Aid

  +

  +/-

  -

  NA

• Personal Protective Equipment

  +

  +/-

  -

  NA

• Powered Industrial Trucks (Forklifts)

  +

  +/-

  -

  NA

• Security

  +

  +/-

  -

  NA

• Stairways

  +

  +/-

  -

  NA

• Storage

  +

  +/-

  -

  NA

• Welding

  +

  +/-

  -

  NA

• +

  +/-

  -

  NA

VISITOR CONTROLS

• Are there visitor and delivery directions upon entering the site?

  Yes

  No

  N/A

• Are there clearly marked designated parking spaces for visitors?

  Yes

  No

  N/A

• Which of the following apply to visitors, check all that apply:

  Select

• Are visitor and employee parking areas physically separated from delivery operations, outside storage and other company operations?

  Yes

  No

  N/A

• Are there controls in place for delivery drivers that restrict or control driver access to the facility?

  Yes

  No

  N/A

• Describe Visitor and Delivery Driver activity, parking areas, and controls

CONTRACTOR CONTROLS

• Is there a formal contractor approval process?

  Yes

  No

  N/A

• Does the insured have formal contractor safety program in place to manage contractors that come onsite?

  Yes

  No

  N/A

• Describe Contractor use, frequency, and controls.

FACILITY CONDITIONS

• Are there controls in place to address walking surfaces at the facility

  Yes

  No

  N/A

• Who is responsible for facility snow and ice removal?

• Who is responsible for addressing wet floor conditions?

• Who is responsible for facility maintenance?

• Are there documented monthly facility inspections?

  Yes

  No

  N/A

• Does facility maintenance include:

  Select

SECURITY/EMERGENCY RESPONSE

• Have there been any changes to security or emergency response procedures since the last visit or most recent ChemPlan application?

  Yes

  No

  N/A

• Has DHS completed a review of the facility?

  Yes

  No

  N/A

• Does security for the facility include the following, check all that apply:

  Select

• Is there a written evacuation plan?

  Yes

  No

  N/A

• Are plans posted with emergency notification numbers and rally points?

  Yes

  No

  N/A

• Are employees trained on evacuation procedures?

  Yes

  No

  N/A

• Are evacuation drills performed?

  Yes

  No

  N/A

• Is there a written emergency response plan?

  Yes

  No

  N/A

• Has a copy of the emergency response plan been provided to the fire department?

  Yes

  No

  N/A

• Are employees trained on fire and spill procedures?

  Yes

  No

  N/A

• Are there process/equipment emergency shutdown procedures?

  Yes

  No

  N/A

• Is there an Emergency Response Contractor on call for a spill response?

  Yes

  No

  N/A

• Describe what the emergency response plan address (fires, spills, weather events, earthquake, etc.) and whenwas it last updated?

• Any coordination or drills or training performed with the local fire department or HAZMAT team?

  Yes

  No

  N/A

• Obtain copy of Emergency/Spill Response Plan

• Spill Response Service reviewed with the site contact?

  Yes

  No

  N/A

• Spill Response Service Handout left with client?

  Yes

  No

  N/A

TOXIC TORT

• Do any of your products (past or present) contain Benzene?

  Yes

  No

  N/A

• Do any of your products (past or present) contain Perfluortanoic Acid (PFOA) or Perfluorooctane Sulfonate (PFOS)?

  Yes

  No

  N/A

• Do any of your products (past or present) contain Silica?

  Yes

  No

  N/A

• Do any of your products (past or present) contain Lead or Asbestos?

  Yes

  No

  N/A

• Do any of your products (past or present) contain BPA (Bisphenol A)?

  Yes

  No

  N/A

• Do any of your products (past or present) contain Phthalates?

  Yes

  No

  N/A

• Do any of your products (past or present) contain Diacetyl?

  Yes

  No

  N/A

• Do any of your products (past or present) use or incorporate Nanotechnology?

  Yes

  No

  N/A

CHEMICAL CONTRACTS/PURCHASE ORDERS

• Is there legal review of all sales agreements (contracts/purchase orders) for all chemicals purchased or sold by your company?

  Yes

  No

  N/A

PRODUCTS

PRODUCT DESCRIPTION

• Have the insured describe their products and their markets/end users, including equipment sales.

• % of Total Sales that are Liquid Products

• % of Total Sales that are Dry/Powder products

• % of Total Sales that are Water-based products

• % of Total Sales that are Aerosol Products

• % of Total Sales that are Flammable/Combustible Products

• % of Total Sales that are Retail Sales

• Any products sold to the following

  Select

• If any of the above are checked, please provide details on the product use.

QUALITY ASSURANCE/QUALITY CONTROL - FOR U.S. SUPPLIERS

• Are they ISO 9001 certified?

  Yes

  No

  N/A

• Does Insured have any other quality certifications?

  Yes

  No

  N/A

• Is there a raw material supplier qualification and approval process?

  Yes

  No

  N/A

• Are Certificates of Analysis (COAs) obtained from raw material suppliers?

  Yes

  No

  N/A

• Any additional laboratory testing of raw materials performed?

  Yes

  No

  N/A

• Are raw material samples retained?

  Yes

  No

  N/A

• Are batch sheets used during manufacturing/blending/repackaging?

  Yes

  No

  N/A

• Are the batch sheets retained?

  Yes

  No

  N/A

• Is laboratory testing of finished products performed?

  Yes

  No

  N/A

• Are finished product samples retained?

  Yes

  No

  N/A

• Do the batch sheets include packaging instructions for containers and labels?

  Yes

  No

  N/A

• Are sign offs and approvals required before a product is approved for packaging?

  Yes

  No

  N/A

• Are Lot or Batch numbers assigned to products?

  Yes

  No

  N/A

• Are the Lot/Batch numbers placed on labels?

  Yes

  No

  N/A

• Describe how you would perform a recall if needed.

FOREIGN SUPPLIER/IMPORTER

• Do you import any products or components for sale directly from foreign suppliers?

  Yes

  No

  N/A
FOREIGN SUPPLIER

• Country

• Product

• Manufacturer

• ISO 9001

  Yes

  No

  N/A

• % of Foreign Total

CONTAINERS

• % of Products packaged and shipped in Bulk (tanker, rail car or similar)

• % of Products packaged and shipped in Totes

• % of Products packaged and shipped in 55 Gallon Drums

• % of Products packaged and shipped 5-gallon pails/containers or smaller containers

• % of Products packaged and shipped in Supersacks

• % of Products packaged and shipped in Bags/Boxes

• % of Products packaged and shipped in pressurized cylinders

• % of Products packaged and shipped by other methods

• % of Products packaged and shipped in New Containers

• % of Products packaged and shipped in Used Containers (reconditioned by others)

• Describe reconditioning and maintenance of containers performed by insured.

• Are there any special container/packaging quality control that is performed on the small container packaged products (<5 gallon size)?

  Yes

  No

  N/A

SERVICE/EQUIPMENT

• Do employees provide regular Service at customer locations such as chemical testing, monitoring chemical feed and inventory, cleaning services, etc?

  Yes

  No

  N/A

• Do you fabricate, assemble, install, or maintain equipment at customer locations (ie pumps, tanks, dispensing equipment, part washers, laundry machines, floor cleaners, etc)?

  Yes

  No

  N/A

APPLICATION OF PRODUCT

• Are any of the products used in building construction or renovation projects including coatings, adhesives,caulks, sealers, asphalt, etc?

  Yes

  No

  N/A

DELIVERY FLEET SAFETY MANUAL AND CAB REVIEW

FLEET SAFETY MANUAL

• Does the insured have a written Fleet Safety Manual for delivery drivers?

  Yes

  No

  N/A

CAB REVIEW - SHOULD BE DONE PRIOR TO SURVEY

• Operation classification, carrier operation, and cargo carried

• # Power Units, # Drivers, Miles driven in what year

• Radius of operation review

• SAFER results and accident review

• ISS and BASIC Scored Review

• OOS and individual roadside inspection report review with insured

  Yes

  No

  N/A

• Describe procedures for a driver turning in the roadside inspection reports and who reviews and discusses results with driver

DELIVERY FLEET STANDARDS - APPLIES TO ALL FLEET DELIVERY OPERATIONS, NOT JUST LOCATION VISITED

• Who is responsible for fleet safety, including driver hiring, training, record-keeping, dispatching, etc.?

• Describe the number and types of trucks, trailers, and tankers along with the delivery operations.

• Average mile radius

• Furthest mile radius

• What is the percentage of deliveries of less than 50 miles?

• What is the percentage of deliveries between 51 and 200 miles?

• What is the percentage of deliveries greater than 200 miles?

DELIVERY VEHICLE USE & SAFETY

• What is the number of CDL Drivers?

• What is the number of Full Time Drivers?

• What is the number of Part Time Drivers?

• Are any Temp Agency or Leased drivers used to make deliveries?

  Yes

  No

  N/A

• Are owner/operators used?

  Yes

  No

  N/A

• Are common carriers used?

  Yes

  No

  N/A

• Are logistics companies used to arrange delivery?

  Yes

  No

  N/A

• Average "In type" driver experience for current company drivers

  Select

• Are selection and qualification standards in writing?

  Yes

  No

  N/A

• Does insured complete past employment checks for new hires?

  Yes

  No

  N/A

• Is there a drug testing program in place?

  Yes

  No

  N/A

• Is a road test given in the size and type of equipment to be operated for all new hires?

  Yes

  No

  N/A

• Does the company utilize "Minimum Driver Eligibility" Criteria for new hires and existing drivers to determine which individuals are acceptable drivers?

  Yes

  No

  N/A

• When was the last time you terminated a driver and why?

• Are MVR's reviewed for new hires and annually for all company drivers?

  Yes

  No

  N/A

• Does insured have driver files on each driver?

  Yes

  No

  N/A

• Request the insured provide information related to the last two terminations as a result of driver's failure to meet minimum criteria.

DRIVER DISTRACTION EXPOSURE

• How do drivers communicate with home office?

• How often and when do drivers communicate with home office?

• Does the company have a cell phone and other electronic device policy?

  Yes

  No

  N/A

• Are there any additional driver/vehicle management systems that are located in the cab which drivers are required to access/utilize in daily operations?

  Yes

  No

  N/A

• Are there any additional Fleet technology systems that are located in truck cab that the CDL driver is required to access during daily operations?

  Yes

  No

  N/A

• Are there any additional technologies used with the fleet such as cameras?

  Yes

  No

  N/A

• For new leased or purchased delivery trucks and tractors did they come equipped with new active or passive safety features?

  Yes

  No

  N/A

• Do any CDL drivers use personal GPS units or Phone based mapping applications for routing?

  Yes

  No

  N/A

VEHICLE MAINTENANCE, MANAGEMENT AND SECURITY

• Written Vehicle Maintenance Criteria that include individual maintenance records or files for all trucksand trailers that include regular preventative maintenance, required inspections, and proof of repairs?

  Yes

  No

  N/A

• Are pre- or post-trip inspections conducted?

  Yes

  No

  N/A

• Maintenance Conducted By: (Check all that apply)

  Yes

  No

  N/A

LOADING/UNLOADING EXPOSURES

• What is the % of drum/tote/smaller containers versus bulk product deliveries that are conducted by your own fleet?

DRUM AND TOTE LOADING/UNLOADING PRACTICES

• Does insured make tote/drum deliveries?

  Yes

  No

  N/A

BULK LOADING/UNLOADING PRACTICES

• Does insured make bulk tanker deliveries?

  Yes

  No

  N/A

ACCIDENT INVESTIGATION

• Does the insured maintain a DOT Accident Register?

  Yes

  No

  N/A

• Are Accident Investigations documented?

  Yes

  No

  N/A

• Include evaluations of all collisions and review with drivers?

  Yes

  No

  N/A

• Are there determinations of preventable/non-preventable accidents?

  Yes

  No

  N/A

NON-DELIVERY VEHICLE USE

• Are there any personal vehicles used by employees for company business?

  Yes

  No

  N/A

• Are there company-owned vehicles used by management, sales, or other employees?

  Yes

  No

  N/A

• Does the policy address personal use of company-owned vehicles?

  Yes

  No

  N/A

• How many non-delivery vehicles and drivers are there?

  Yes

  No

  N/A

• Are there any Fleet Technologies including GPS tracking and Mobile Phone-based applications used with the cars and pickup trucks used for sales, service, technicians, and other non-delivery drivers?

  Yes

  No

  N/A

LOCATION(S)

• Location Address

HISTORICAL OWNERS OF THE SITE

• Owner Name

• Description of Operations

• Years Present

• Past environmental concerns

  Select

• If any boxes were checked, describe how they were addressed at the site and with the regulatory agencies involved.

• Obtain copies of final reports or correspondence with regulatory agencies for each past concern, especially those addressing final approval or closure of the concern.

• Describe any changes to the tank schedule in file or current ChemPlan application.

• Are underground storage tanks present and in use at the site?

  Yes

  No

  N/A

• Are aboveground storage tanks present and in use at the site?

  Yes

  No

  N/A

• Does the building provide containment or is it sloped so that a spill or release inside the building will not reach outside?

  Yes

  No

  N/A

• Are there any outside operations or storage on bare earth?

  Yes

  No

  N/A

• Are bulk tanker, van trailer, and railcar loading and unloading areas paved/concrete and provided with containment?

  Yes

  No

  N/A

• Are there any drains, concrete catch basins or vaults, or underground storage tanks used to collect spilled materials?

  Yes

  No

  N/A

• Describe the surrounding properties.

• Describe where stormwater or firefighting water flows from the site.

• Describe any plans for future development, improvement, excavation or demolition.

• Are there any plans to sell any of the insured location?

  Yes

  No

  N/A

• Are flammables dispensed or repackaged?

  Yes

  No

  N/A

• Are incompatible materials properly segregated?

  Yes

  No

  N/A

• Are there any exothermic reactions for manufactured products?

  Yes

  No

  N/A

• For consultant - please summarize the attached EDR report and EPA ECHO report, along with any additional environmental studies or assessments obtained during survey.

• EDR Report Summary

• EPA ECHO Summary

• Environmental Reports Summary