Audit

Loss Control Survey / Rating Sheet
Select 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

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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.