VL 1

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Loss Control Survey / Rating Sheet

• Select date

  Date

• Customer:

• Van line affiliation:

• Owner w/email:

• Coverages (check all that apply):

• BA

• WC

• CG

• GL

• GR

• PROP

• UM

• Loss Control Rep:

• Customer contact:

• Contacts Position:

• Contact's email:

• Address of Location(s) visited:

GENERAL SAFETY RATING

• Formal Safety Program:

• Points Earned:

• Points Possible:

• Score%

• Background Investigations

• Points Earned:

• Points Possible:

• Score%

• Inspection Program:

• Points Earned:

• Points Possible:

• Score%

• Ongoing Training:

• Points Earned:

• Points Possible:

• Score%

• Field Safety Inspections:

• Points Earned:

• Points Possible:

• Score%

• Drug / Alcohol Program:

• Points Earned:

• Points Possible:

• Score%

AUTO RATING

• Driver Safety: PTS Earned PTS Possible Score%

• Vehicle Safety: PTS Earned PTS Possible Score%

• Property Damage LC: PTS Earned PTS Possible Score%

• Claims Cost Control: PTS Earned PTS Possible Score%

WORKERS' COMPENSATION RATING

• Injury Prevention: PTS Earned PTS Possible Score%

• Claims Cost Control: PTS Earned PTS Possible Score%

GENERAL LIABILITY RATING

• Delivery Installation LC: PTS Earned PTS Possible Score%

• Claims Prevention: PTS Earned PTS Possible Score%

• Claims Cost Control: PTS Earned PTS Possible Score%

PROPERTY / CARGO RATING

• BLDG/PROP/Protection: PTS Earned PTS Possible Score%

• Cargo Loss Prevention: PTS Earned PTS Possible Score%

• Claims Cost Control: PTS Earned PTS Possible Score%

OVERALL CUSTOMER RATING

• Customer Score: ( ) Points Earned ( ) Points Possible Final Score: ______________%

• Points Earned:

• Points Possible:

• Final Score%:

SUGGESTIONS

• 1. Status: Addressed?

• Yes

• No

• Comments:

• 2. Status: Addressed?

• Yes

• No

• Comments:

• Please review the suggestions listed above and send a brief response using the following page regarding corrective action taken or planned for our underwriters. Please send this to my attention within 30 days via email: Loss Control Rep. email: Fax: 636-305-4766 Thank you for being a Vanliner customer. Hopefully you found the visit and suggestions beneficial to your overall loss control program. Remember to check out our resources,videos,DVD's and newsletters on our website at www.vanliner.com under Services/Loss Control. Please feel free to contact me in the future at 800-325-3619 ext _____ or by email for loss control assistance. _________________________ _________________________ (Signature of LC Rep.) (Date)

• 3. Status: Addressed?

• Yes

• No

• Comments:

• 4. Status: Addressed?

• Yes

• No

• Comments:

• 5. Status: Addressed?

• Yes

• No

• Comments:

• Visit of:

• Safety incentive program

• Return to work policies/procedures

• Select from range

• Testing entry

Background Investigations

Inspection Program

• Housekeeping warehouse/office favorable

• Housekeeping lot favorable

Ongoing Formal Training

• DDT orientation, ongoing, & high-risk drivers documentation

• Ongoing training (i.e. safety meetings) documentation