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Loss Control Survey

Walks insurance inspectors through a loss control visit or phone review with a policyholder. It covers operations, staffing, safety programs, on-site hazards and vehicle fleet, and ends with the inspector's view of the risk.

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In the Claude connectors directory

Page 1

Underwriter special instructions

Special attention: are there special instruction items?

Yes No Not applicable

Special instructions (copy and paste the underwriter's instructions)

Response to special instructions

General information

Name and title of person interviewed

First Name

Last Name

Phone of person interviewed

Email of person interviewed

Type of business

Sole proprietorship Partnership Corporation LLC Nonprofit

Years in business

Under 3 3 to 5 6 to 10 Over 10

Years at current location

Management experience (in years)

Under 3 3 to 5 6 to 10 Over 10

Number of company owners

Number of owners active in daily operations

USL&H (longshore and harbor) exposure?

Yes No Not applicable

Description of USL&H exposures

Section

Workers' compensation claims in the last 5 years

None 1 to 2 3 to 5 More than 5

Describe past workers' compensation claims: injury types by year, trends and corrective actions taken. If there were none, submit recommendations.

OSHA fines or citations in the last 5 years

Yes No Not applicable

Description of OSHA fines or citations

Are OSHA-required records maintained?

Yes No Not applicable

Page 2

Operations

Description of operations

Is there a dedicated safety employee?

Yes No Not applicable

Percentage of subcontractor usage

Subcontractor controls

Written contracts Certificates of insurance Hold-harmless agreements Safety requirements None

Are copies of certificates of insurance kept?

Yes No Not applicable

Are uninsured subcontractors used?

Yes No Not applicable

Percentage of uninsured subcontractor usage

Description of subcontractor duties

Does the insured operate as a temporary staffing firm?

Yes No Not applicable

Section

Number of full-time employees

Number of part-time employees

Number of temporary employees

Number of seasonal employees

Number of leased employees

Annual turnover percentage

Under 10% 10% to 25% 26% to 50% Over 50%

Average hourly rate

Under 15 15 to 25 26 to 40 Over 40

Annual payroll (enter "N/A", "Unknown" or "Not disclosed" if there is none)

Employee activities, broken down by job duty

Piece work

Yes No Not applicable

Volunteer labor

Yes No Not applicable

Section

Employee selection procedures

Job application Interview Reference checks Background checks Pre-employment physical Skills test

Other employee selection procedures

Drug and alcohol testing program

Written policy Verbal only No policy

Testing program scope (check all that apply)

Pre-employment Random Post-accident Reasonable suspicion Return to duty

Are medical benefits provided?

Yes No Not applicable

Percent of medical benefits paid by the company

Describe the medical benefits program

Return-to-work program

Written policy Verbal only No policy

Please provide details

Section

Formal written safety program

Yes No Not applicable

Is a safety committee used?

Yes No Not applicable

Frequency of safety committee meetings

Employee safety meetings

Yes No Not applicable

Frequency of employee safety meetings

Are meetings documented?

Yes No Not applicable

Is there a progressive disciplinary program?

Yes No Not applicable

Safety incentives?

Yes No Not applicable

Safety incentive description

Formal accident investigation procedures

Yes No Not applicable

Do they include taking photos to document the accident or incident?

Yes No Not applicable

Do they include formal documentation and reporting?

Yes No Not applicable

Are self-inspections or safety inspections performed?

Yes No Not applicable

Do you have at least one medical provider you send injured employees to?

Yes No Not applicable

Page 3

On-site hazards

Weight of materials lifted by hand

Under 25 lb 25 to 50 lb Over 50 lb No manual lifting

Are forklifts or other powered industrial trucks in use?

Yes No Not applicable

Are forklift operators trained or certified?

Yes No Not applicable

Flammable, combustible or hazardous materials on site

Section

Any excavation or trenching exposures?

Yes No Not applicable

Describe excavation exposures and controls

Does the policyholder perform municipal line work?

Yes No Not applicable

To what depth are trenching operations carried out?

Section

Work done at height

Yes No Not applicable

Ladder use

Yes No Not applicable

Ladder safety inspection

Yes No Not applicable

Is fall protection equipment training provided?

Yes No Not applicable

Is fall protection training documented?

Yes No Not applicable

Testing and repair or replacement program for fall arrest systems

Yes No Not applicable

If roofing, are controlled access zones set up per 1926.502 with enough distance from the roof edge?

Yes No Not applicable

Fall protection comments

Section

Are respiratory hazards present?

Yes No Not applicable

Describe respiratory exposures

Is there a respiratory protection program (OSHA 1910.134, with fit testing, medical exam, proper equipment, cleaning and maintenance)?

Yes No Not applicable

When is the respiratory exam done?

Before assignment Annually After an exposure Not performed

Is fit testing done for all respiratory equipment?

Yes No Not applicable

Is there a respiratory equipment upkeep or replacement program?

Yes No Not applicable

Section

Confined space exposure

Yes No Not applicable

Describe confined space operations

Is a confined space permit in place when required?

Yes No Not applicable

Section

Do the insured's employees operate heavy equipment?

Yes No Not applicable

Describe the heavy equipment used

The equipment is:

Owned Leased Rented A mix

Are employees trained or certified to operate the heavy equipment?

Yes No Not applicable

Describe who handles inspection and maintenance of the heavy equipment

Page 4

Is there auto exposure?

Yes No Not applicable

Are any fleet vehicles subject to DOT FMCSR?

Yes No Not applicable

DOT number

Vehicle types

Cars Vans Pickup trucks Box trucks Tractor-trailers Dump trucks

Number of cars

Car use description

Number of vans

Van use description

Number of pickup trucks

Pickup truck use description

Number of box trucks

Box truck use description

Number of tractor-trailers

Tractor-trailer use description

Number of dump trucks

Dump truck use description

Are vehicles used to carry more than two employees anywhere?

Yes No Not applicable

Radius of operations

Local (under 50 miles) Intermediate (50-200 miles) Long haul (over 200 miles)

Are vehicles operated daily?

Yes No Not applicable

Cellphone use policy

Written policy Verbal only No policy

Seatbelt use policy

Written policy Verbal only No policy

Driver selection controls

Motor vehicle record checks Minimum age Minimum experience Road test Driver training

Vehicle maintenance procedures (check all that apply)

Scheduled maintenance Pre-trip inspections Maintenance records In-house shop Outside vendor

Hired or non-owned auto exposure

Yes No Not applicable

Describe hired or non-owned auto exposure and controls

Hired and non-owned auto controls in place

Proof of personal insurance Motor vehicle record checks Written policy None

Opinion of risk

Above average Average Below average Unacceptable

Opinion justification

Were recommendations made?

Yes No Not applicable

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