WCS4. Auto Owners WCS4 Account / Account Code: Insured: Policy #: Survey Address: Policy Information. General Information

Transcription

1 WCS4 Auto Owners WCS4 Account / Account Code: Agency: Insured: Policy #: Survey Address: Telephone: Alt. Phone: Policy Information Report Status: (Choose one value) [_]Productive [_]Non-Productive (describe) [_]Pending Survey Date: Description of Operations (Start to Finish) Narrative: General Information Answers to Special Instructions from underwriting: Name / Title of person interviewed: Insured is a/an: (Choose all that apply) [_]Individual [_]Corporation [_]Association [_]Partnership [_]LLC [_]Other (describe) Year Business Started: Hours of Operation: Seasonal Business: (Choose one value) Number of Owners, Corporate Officers, Partners or LLC Members: List names of Owners, Partners or LLC Members: Number of employees FT: Number of employees PT: Total estimated annual payroll: Number of Locations: List all the states the insured operates in: Past Loss History: Management & Safety Practice Owners are actively involved in the daily operation of the business: (Choose one value) The insured has been cited for an OSHA violation: (Choose one value) Insured maintains an OSHA 300 log: (Choose one value) [_]N/A A written safety, security, or risk management plan is in place: (Choose one value) Regular safety meetings held: (Choose one value) Frequency: Records are kept of training programs, workplace injuries, and inspections: (Choose one value) Provide a description of the insured's workplace safety and security program: Insured utilizes the lockout / tagout (LOTO) method when performing maintenance on equipment: (Choose one value) [_]N/A All employees who work in the area where LOTO procedures are in place are trained to ensure they know, understand, and are able to follow the applicable provisions of the LOTO procedures: (Choose one value) [_]N/A

2 All employees who are authorized to lockout and perform service and maintenance operations are trained in recognition and handling of applicable hazardous energy sources: (Choose one value) [_]N/A Proper personal protective equipment (PPE) is provided (or specifically required) by the insured and used: (Choose one value) [_]N/A If yes, list what PPE is required: Employees are trained in the use of PPE and required to use it at all times: (Choose one value) [_]N/A All PPE is inspected regularly by the insured to assure proper operation: (Choose one value) [_]N/A Insured has the names and contact information of certified occupational medical providers: (Choose one value) Georgia only - The provided panel of physicians is posted: (Choose one value) [_]N/A Insured provides health insurance program to employees: (Choose one value) Insured has employees working out of the primary state of operation or out of the country: (Choose one value) If yes, list states and countries: Average duration of trips: Insured has an evening or after hours work policy: (Choose one value) [_]N/A Insured conducts regular inspections of the facility: (Choose one value) Occupational Health Exposures Employees are protected against Extreme hot or cold working conditions: (Choose one value) [_]N/A Contaminant contact with skin (e.g. chemical burns): (Choose one value) [_]N/A Contaminant absorption through skin (e.g. poisonous chemicals): (Choose one value) [_]N/A Inhalation of contaminants (fumes / vapors / particulates): (Choose one value) [_]N/A Ingestion of contaminants (food / beverages): (Choose one value) [_]N/A Blood borne pathogens: (Choose one value) [_]N/A Material Safety Data Sheets (MSDS) maintained and readily accessible: (Choose one value) [_]N/A Work Place Exposures Insured operation presents a contracting exposure: (Choose one value) [_]Yes (describe contracting exposure in narrative) [_]No Insured operation presents an automotive sales and/or repair exposure: (Choose one value) [_]Yes (describe automotive exposure in narrative) [_]No Insured operation present a manufacturing exposure: (Choose one value) [_]Yes (describe manufacturing exposure in narrative) [_]No Insured operation presents a restaurant exposure: (Choose one value) [_]Yes (describe restaurant exposure in narrative) [_]No The workplace is free of slip, trip, and fall hazards: (Choose one value) Interior and exterior lighting is sufficient: (Choose one value) Exits and walkways are free of clutter: (Choose one value)

3 Occupations present a heavy lifting exposure (Greater than 35lbs): (Choose one value) Lifting devices are provided (if yes, describe type and condition): (Choose one value) [_]N/A Employees are trained in proper lifting techniques ande use of devices if present (if yes, describe training procedure): (Choose one value) [_]N/A Employees work around Overhead obstructions: (Choose one value) Excessive heat, open flame, or fire: (Choose one value) Flammable liquids or volatile vapors: (Choose one value) Explosives (e.g. metal or grain dust, flour, demolition materials, etc.): (Choose one value) Chemicals, corrosives, or caustic materials: (Choose one value) Excavations / underground dangers: (Choose one value) Abrasion, scrape, or cut hazards: (Choose one value) Excessive noise levels: (Choose one value) Welding, cutting, and/or brazing: (Choose one value) Sharp instruments / tools: (Choose one value) The potential for electrical shock: (Choose one value) Potential respiratory hazards (e.g. dust, airborne biological hazards, mists, fumes, sprays, gases, vapors and other airborne particles): (Choose one value) Employees are exposed to repetitive motion or vibration syndrome: (Choose one value) Employees operate forklifts: (Choose one value) Formal forklift training is provided to employees: (Choose one value) [_]N/A The insured owns or operates an aircraft: (Choose one value) List the types of equipment used in the workplace: Equipment / Machinery guarding & safety controls are adequate: (Choose one value) [_]N/A Employees receive adequate equipment training: (Choose one value) [_]N/A Maintenance of equipment is done in a timely manner: (Choose one value) [_]N/A All elevators / lifts are properly enclosed: (Choose one value) [_]N/A All stairwells, catwalks, or other elevated area have proper railings: (Choose one value) [_]N/A Compressed gas cylinders are stored properly: (Choose one value) [_]N/A The insured is involved, to any extent, with hydraulic fracturing (hydrofracking): (Choose one value)

4 Employees and Hiring Practices Seasonal or transient employees are used: (Choose one value) Volunteer laborers are used: (Choose one value) Leased employees are used and/or employees are leased to others: (Choose one value) Insured hires temporary labor in states where temporary work is being performed: (Choose one value) [_]N/A Any individuals or companies were hired by contract to perform any type of work or service (subcontractors): (Choose one value) If yes, certificates of insurance for Workers Compensation and General Liability or state approved exemption forms are obtained for all subcontractors: (Choose one value) [_]N/A Additional Insured status required: (Choose one value) Formal contract is used stating insurance requirements: (Choose one value) Hold Harmless agreements are used with subcontractors: (Choose one value) There is an United States Longshoreman and Harbor Workers Act (USL&H) exposure: (Choose one value) Average number of years employees have been with the company: Insured uses written applications: (Choose one value) Insured has a formal hiring procedure: (Choose one value) Every position has a written job description: (Choose one value) A medical examination / physical fitness-for-duty test is required post-offer / pre-employment: (Choose one value) Periodic physicals are required as a condition of employment: (Choose one value) Insured requires post-accident / incident drug / alcohol screening: (Choose one value) Insured performs background screening procedures for perspective employees: (Choose one value) Insured has a formal written safety manual: (Choose one value) If yes, all employees receive a copy and sign off on it: (Choose one value) Describe consequences for not following the safety procedures: A formal training program is provided to employees: (Choose one value) Employees are subject to a probation period; how long: (Choose one value) Describe the training process: A formal return to work or modified / light duty program is in place: (Choose one value) Vehicle / Driving Exposures There are drivers under 21 years of age: (Choose one value) [_]N/A There are drivers over 65 years of age: (Choose one value) [_]N/A Motor Vehicle Records are checked for all drivers: (Choose one value)

5 [_]N/A Driver training is provided: (Choose one value) [_]N/A Radius of travel for company vehicles (miles): Delivery exposures are present: (Choose one value) [_]N/A Employees are required to adhere to a time schedule for deliveries (if yes, describe policy): (Choose one value) [_]N/A Company vehicles are equipped with boom lifts or any other types of attached equipment (if yes, describe type and condition of vehicles): (Choose one value) [_]N/A Vehicles and equipment serviced by insured: (Choose one value) [_]N/A A vehicle and equipment maintenance schedule is maintained (if yes, describe policy): (Choose one value) [_]N/A If no, the service provider is: Contractors Exposures Jobsite (address) where inspection was performed: Type of construction work the insured performs: Insured's years of management experience in this industry: A supervisor or site manager is on site when work is being performed: (Choose one value) Employees are: (Choose one value) [_]Union [_]Non-union [_]Both Employees frequently travel between jobsites on a daily basis: (Choose one value) Job site safety procedures are in place and communicated to the employees: (Choose one value) Toolbox talks are a regular part of continuous training: (Choose one value) Employees are trained on the proper use of portable tools and equipment: (Choose one value) Equipment and tool guards are in place: (Choose one value) Tools and equipment are properly grounded: (Choose one value) The equipment and tools are inspected prior to use: (Choose one value) Employees are required to report damage or defective equipment and tools: (Choose one value) Ladder, elevated platform, or scaffolding work performed (if yes, provide details of the Formal Fall Protection Program): (Choose one value) [_]N/A If working in residential construction, are they following OSHA's Fall Protection in Residential Construction guidelines: (Choose one value) [_]N/A Scaffolding and/or ladders are in good condition and secured properly when being used: (Choose one value) [_]N/A When working on heights of more than 6 feet, employees are protected by guardrails, safety net systems or personal fall arrest systems: (Choose one value) [_]N/A The insured is in compliance with all applicable OSHA regulations: (Choose one value) Garage Exposures Insured's years of management experience in this industry: A supervisor or manager is on site at all times during business hours: (Choose one value)

6 Mechanics are state certified: (Choose one value) There is a towing exposure: (Choose one value) [_]Yes (describe and is it 24 hours) [_]No There is a spray painting exposure: (Choose one value) If yes, the booth meets AOIC requirements: (Choose one value) Flammable liquids are properly labeled and stored a safe distance from potential ignition sources: (Choose one value) Hoists are well maintained and inspected on a regular basis: (Choose one value) [_]N/A Car lifts and pits / floor openings are clearly marked and covered or otherwise guarded: (Choose one value) [_]N/A Walking surfaces are cleaned and maintained to prevent slips and falls: (Choose one value) The shop is properly ventilated to prevent carbon monoxide buildup: (Choose one value) The insured works on vehicles that have been involved in accidents: (Choose one value) If yes, describe the precautions taken to protect workers from exposure to bloodborne pathogens: Proper fire extinguishing equipment is in place: (Choose one value) When working with tires, they are always mounted to a mounting machine, vehicle or stored in a cage: (Choose one value) [_]N/A Manufacturing Exposures Type of manufacturing insured performs: Insured's years of management experience in the industry: List the number of shifts and working hours for each shift: Danger zones around machinery are clearly marked: (Choose one value) [_]N/A Machinery has the proper guards in place: (Choose one value) [_]N/A Equipment is properly grounded: (Choose one value) [_]N/A Equipment is bolted to the ground, if possible, to prevent movement: (Choose one value) [_]N/A Startup and shut off controls are clearly marked: (Choose one value) [_]N/A Employees are trained on the proper use of all equipment: (Choose one value) [_]N/A Machinery and equipment is inspected prior to use: (Choose one value) [_]N/A When new equipment is purchased, a safety review of that equipment is evaluated: (Choose one value) [_]N/A There is a routine maintenance program for the equipment: (Choose one value) If yes, any deficiencies and repairs are documented and retained: (Choose one value) Employees are required to report defective / damaged equipment: (Choose one value) Shop safety procedures are clearly posted: (Choose one value) Any usage of robotics: (Choose one value)

7 If yes, explain how the employees interact with them: Insured has a dust collection system: (Choose one value) [_]N/A If yes, it is serviced regularly and adequate records maintained: (Choose one value) Walking surfaces are cleaned and maintained to prevent slip and falls: (Choose one value) All changes in surface elevations are properly marked and identifiable and proper precautions are taken to prevent employee injury: (Choose one value) Restaurant Exposures Type of restaurant (e.g. family, pizza, fine dining, casual dining, bar, etc.): Number of years in restaurant management: Off-premises catering is provided: (Choose one value) [_]N/A The insured has a dance floor and/or entertainment: (Choose one value) The insured employs bouncers, doormen, or other security personnel: (Choose one value) [_]N/A The insured obtains Workers Compensation certificates of insurance for all entertainers: (Choose one value) [_]N/A There are current violations for fire, safety, building, or construction codes: (Choose one value) Illuminated exits signs are in place and in good working order: (Choose one value) Knives and sharp instruments are properly stored: (Choose one value) Employees are trained on the proper use of cutting utensils: (Choose one value) All equipment is on a routine schedule for maintenance: (Choose one value) There is proper training for handling hot pans, trays and dishes: (Choose one value) Employees are trained on the carrying of heavy dish loads between the kitchen and the serving area: (Choose one value) [_]N/A There are non-slip padded mats in the bar and kitchen area: (Choose one value) The insured has the proper extinguishing system in place for all cooking appliances: (Choose one value) Uniforms / safety apparel is required for the appropriate positions: (Choose one value) Describe the security procedures for late night closing and cash deposits: Narrative & Overall Assessment Narrative: