Underwriting Survey Report

Survey Information

• Insured

• Address

• Survey Type

  Select

• Survey Date

  Date

• Consultant

Insured Contact(s) Interviewed

• Name, Title, Phone, Email

• Have there been any changes or anticipated changes in the past 12 months or the next 12 months?

  Yes

  No

  N/A

• Prior Recommendations

• Prior Recommendation Follow-Up

• Special Underwriting Concerns

• Special Underwriting Concerns Follow-Up

• Follow Up Documentation and Information

Loss Analysis Summary

• Describe claim types and trends

• Note top three (3) loss type categories and document whether you feel they are adequately controlled

Large Loss Review

• Please describe the trigger, cause and corrective action

• Is there more than one insured facility or location with fleet operations and employees?

  Yes

  No

  N/A

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

• The following processes are in place for visitors:

  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

• The following items are included in facility maintenance:

  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

• The following security measures are present:

  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 addresses (fires, spills, weather events, earthquake, etc.) and when was 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 bisphenol A (BPA)?

  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

• Describe the products that are sold retail

• Products sold to identified industries

  Select

• 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)

• % of products packaged and shipped in used containers (reconditioned by insured)

• 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 temporary agencies 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 trucks and 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 is performed by:

  Select

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?

• 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

• Location Address

Historical Property Owner

• Property Owner Name

• Description of Operations

• Years Present

• Past environmental concerns

  Select

• Describe how the issue(s) was/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.

• Attach the updated tank schedule here

• 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

• EDR Report Summary

• EPA ECHO Summary

• Environmental Reports Summary

Health and Safety Plan and OSHA Inspections

Health and Safety Plan

• Does insured have a written Employee Health and Safety Program?

  Yes

  No

  N/A

OSHA Inspections

• Any OSHA Inspections over the past 10 years that involved a Fatality, Accident, or Complaint?

  Yes

  No

  N/A

Employee Health and Safety Exposure

Employement/Hiring/Training

• Who is responsible, at this location for employee safety including hiring, training, record-keeping, etc.?(Also, please provide a short summary of their years with the company, background and work experience.)

• Describe new hire training and refresher training.

• Have there been or are there any anticipated changes to the hiring procedures?

  Yes

  No

  N/A

Return to Work

• Does the company have return to work (RTW) policies, procedures and/or training materials?

  Yes

  No

  N/A

• Does the employer have written job description profiles that outline physical job demands?

  Yes

  No

  N/A

• Does the company utilize predefined temporary work assignments that would be available for injuredemployees?

  Yes

  No

  N/A

• How many employees have been currently (or within the last six months) designated as "off work" due to"lost time" injury?

• Does the new hire physical include or utilize job fitness (Functional Capacity) testing?

  Yes

  No

  N/A

• Are job descriptions in a format and available to be reproduced and taken to the doctor in the event of a workplace injury?

  Yes

  No

  N/A

• Does the company have an arrangement with charitable/non-profit organizations to prove alternative jobs that could be utilized for recuperating injured workers?

  Yes

  No

  N/A

• Is there an individual that routinely communicates with all injured/absent workers regarding current health progress, plans for next medical appointment and any challange/obstacles in the treatment progress?

  Yes

  No

  N/A

Workplace Facility Exposures - Material Handling

• Material handling results in any of the following

  Select

Workplace Facility Exposures - Forklifts/Pallet Jacks

• Are there initial and recurring training that address safe material handling? (i.e. classroom, skills and testing)

  Yes

  No

  N/A

• Are forklifts equipped with rollover protection systems?

  Yes

  No

  N/A

• Are there designated traffic ways?

  Yes

  No

  N/A

• Are forklifts equipped with back-up alarms, horns and mirrors?

  Yes

  No

  N/A

Workplace Facility Exposures - Housekeeping

• Are facility floors kept clean and dry?

  Yes

  No

  N/A

• Are floor surfaces kept smooth and level?

  Yes

  No

  N/A

• Aisle ways and egress kept clear of obstruction and clutter?

  Yes

  No

  N/A

• Is there recurring waste disposal and waste pickup?

  Yes

  No

  N/A

Workplace Facility Exposures - Personal Protective Equipment (PPE)

• Are employees provided appropriate PPE to the job task?

  Yes

  No

  N/A

• Please indicate the kind of PPE provided

  Select

• Is there observation and enforcement (supervisor oversight) to ensure utilization of all issued PPE?

  Yes

  No

  N/A

Workplace Facility Exposures - Openings

• Are temporary openings appropriately marked and guarded?

  Yes

  No

  N/A

• Are permanent openings appropriately marked and guarded?

  Yes

  No

  N/A

Workplace Facility Exposures - Stairways & Mezzanine Areas

• Are production floor and mezzanine stairways marked, protected and surfaced per OSHA standards?

  Yes

  No

  N/A

• Are any of the following present: Bulk AST, rail car, tanker, loading/unloading station?

  Yes

  No

  N/A

Workplace Facility Exposures - Fall Protection Program

• Are there "working at elevation" (i.e. ladders, scaffolding, man lifts) exposures that will require a specific fall protection program?

  Yes

  No

  N/A

Workplace Facility Exposures - Others

• Please describe:

Delivery Exposures

• Material handling results in the following:

  Select

• Bulk product deliveries, the following PPE procedures are employed:

  Select

• Which of the following measures are in place to prevent slip/trip/falls in and around delivery vehicles?

  Select

• Are precautions (i.e. safety cones) utilized to protect delivery driver from road traffic hazards?

  Yes

  No

  N/A

Employee Injury Accident Investigation

• Can the employer produce OSHA 300 logs for the prior 3 years?

  Yes

  No

  N/A

• For each recordable instance, is there documented accident investigation?

  Yes

  No

  N/A

• What changes resulted from any/all of investigation?