Title Page
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Company Name
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Conducted on
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Prepared by
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Location
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Describe the operations
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Identify the primary exposures and controls for General Liability
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Identify the primary exposures and controls for Auto Liability
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Identify the primary exposures and controls for Workers Compensation
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If applicable, describe any Product Liability and/or completed operations exposures and controls
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Describe Loss Trends
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Analysis of any large losses over $100,000
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Description of any OSHA citations over the last 5 years
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Opinion of Risk
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Risk improvement recommendations
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Do they have a written safety program?
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Is there a safety policy statement approved and communicated by owners, management or key personnel?
Workers Compensation
Detailed description of the operations
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Do they have a written safety program?
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Is there a safety policy statement approved and communicated by owners, management or key personnel?
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Does the industry specific safety rules, requirements and applicable regulatory compliance meet or exceeds requirement?
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Is there a safety training program description, including new employee orientation plan, that is appropriate for the hazards involved in the members operations?
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Is this training documented?
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Will this training include both workers and supervisors?
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Does the company have an accident and injury reporting policies and procedures?
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Is immediate reporting required of all injuries, no matter how minor they may seem at the time of the incident?
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Does this policy apply to all employees, including supervisors that have knowledge of an incident?
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What is the purpose of accident investigation and reporting?
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Does the accident investigation and reporting program including the employee report of accident (whenever possible)?
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Does the accident investigation and reporting program include supervisors’ accident investigation report?
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Does the accident investigation and reporting program include witness reports and other relevant written reports?
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Is there photo document of accident and injury scenes to augment written reports?
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Do the company report workers’ compensation claims (including notice only) to the TPA (Sedgwick) claims adjuster within 24 hours of the employee reporting the occurrence of the injury?
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Is the transitional return to work program capable of accommodating reasonable restrictions that may be imposed on injured workers, where appropriate?
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Is there a procedure for maintaining regular contact with workers who are out of work with long term injuries?
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Please describe safety observation and inspection program
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Inspections will be documented and conducted periodically to identify potentially unsafe behaviors and conditions.
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Is there corrective action plan?
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Is the corrective action plan tracked through completion based on information collected during safety inspections?
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Is there a documented program of regular safety communications (i.e. Toolbox Talks, Lessons Learned, Procedure Updates...ETC
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What is the process for determining hazards associated with work tasks and their method of controls?
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Does the process for determining hazard include the communication of hazards to the employees?
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Is there a substance abuse policy which includes a drug testing program in accordance with Federal, State and local laws?
Cost Containment Programs
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Does the company utilize virtual medical/nurse triage services for non-emergency employee injuries?
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Does the company have a relationship with a clinic, physician, or hospital for treating employee injuries and assisting with return to work programs?
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Is the clinic in network?
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Is there a written position description that covers the physical and essential functions, including safety responsibilities, of each position?
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Are the position's physical demand's and essential functions explained to prospective hires?
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Is there an acknowledge statement signed?
Auto Loss control
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Is there a written program that adequately addresses their driving exposures and controls (including minimum driver age and experience)?
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Do authorized drivers have a valid license and two years of driving experience, prior to being allowed to operate a vehicle for company purposes ?
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Does the company have a system set up to ensure that all vehicles are in a safe working condition?
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Are there parameters regarding personal use of company vehicles?
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Is there a vehicle use agreement that is signed by each driver?
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Does the company allow any employee who is provided a company vehicle to utilize the vehicle as transportation for any type of personal side business such as (but not limited to): Uber, Lyft, Uber Eats, GrubHub, Shipt, or DoorDash?
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Does the company obtain Motor Vehicle Reports (MVR) for all persons who drive during the conduct of company business (company vehicles or otherwise), including spouses and other family members (as applicable)?
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MVR’s will be obtained upon hire and/or prior to operating a company vehicle, and annually thereafter.
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Does the company obtain a signed release from each driver prior to running an MVR?
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Is there an established MVR acceptability standard?
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Do their standards restrict drivers with more than 3 at fault crashes and/or 3 moving violations?
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Does the MVR standard standard exclude major violations including...
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Leaving the scene of an accident
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Driving under the influence of alcohol or drugs
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Driving under suspended license for driving offenses
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Fleeing a police officer
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Vehicle theft
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Use of vehicle in drug trafficking, reckless homicide, unlawful use of weapons, or any criminal conviction
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Is there a procedure requiring individuals with driving privileges to immediately inform management of any license revocations, restrictions, suspensions or tickets
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Is proof of insurance obtained from employees who drive their personal vehicle to conduct company business?
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Are there minimum coverage requirements of $100,000 per person $300,000 per accident (or $300,000 combined single limit)?
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Is there a procedure to address distracted driving, to include prohibiting handheld electronic device use, and reading and/or sending electronic communication while operating a vehicle?
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Does the company's fleet of commercial motor vehicles meet all Department of Transportation (DOT) requirements, including testing specifications and medical requirements?
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Do they conduct driver awareness training for all employees who drive company vehicles or regularly drive during the conduct of company business?
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Is there an internal procedure which includes provisions that all autos will be equipped with an accident investigation form and that accidents will be immediately reported, and a review will be conducted?
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Are all drivers and passengers to wear seat belts and only ride in seats installed by the vehicle manufacturer?
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Do all company vehicles have in vehicle monitoring systems?
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Ability to detect and report speeding
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Ability to capture G-force events, including crashes
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Outward and driver facing cameras that recognize driver behaviors, classify events and provide the company the ability to correct driver behaviors
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Artificial Intelligence that detects distracted driving, following distance, seat belt use and incomplete stops
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A program in place to ensure events are reviewed and coached in a timely manner
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Is There a crisis management plan in place to handle catastrophic situations that may arise?
General Liability
Risk Transfer
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Are there a minimum insurance requirements for vendors/subcontractors and other service providers?
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Does the company have a designated individual to receive, review, approve, and file certificates?
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If utilizing a temporary agency, does the temp agency cover the workers comp?
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Is their broker or a legal professional involved in all risk transfer agreements?
Quality Control
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Is there a documented Quality Control Standards?
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If an end user product is manufactured, are the quality controls in place adequate?
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Is there any warranty expressed or written?
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Does the company conduct training sessions and/or provide educational information for appropriate personnel on General Liability guidelines/practices and how to avoid a claim?
Non-Employee Access to Worksite
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When responsible for worksite and/or business, Is there a program to effectively manage, control, and monitor non-employee access to worksites and/or businesses, including assignment of escort(s), and orientation of guests (hazards, evacuation plans, etc.)?
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When appropriate, are waivers/releases for non-employees entering worksites and/or businesses utilized?
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When applicable, are all visitors required to wear the necessary personal protective equipment for the area of operation visited?
Incident Investigation
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Does the company have an effective Incident Investigation program for actual incidents which might or might not become an issue of potential liability in the future?
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. This program will include conducting full investigations, interviewing witnesses and involved parties, and documentation of the known facts (who, what, where, when and why) into a written report with supporting photographs whenever possible. If video of an incident is available make sure to preserve it for the investigation.
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What is the standard for reporting any claims to their Broker/TPA (Sedgwick)?
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Is there an appropriate personnel who has access to a camera (phone camera is acceptable), a fresh roll of film, and extra batteries while on job sites or at any company locations (recommend film and digital) as well as access to Incident Investigation Forms?
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Is there training for all pertinent personnel on how to respond to and report an incident?
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Is there a list of experts for the “high risk” areas in their businesses as applicable?
