Phone Survey
Special Attention
Special attention- Special instruction items:
Yes
No
Special Instructions: (Copy and paste special instructions from UW here)
Special Instructions Response
General Survey Information
Name and Title of person interviewed
First Name
Last Name
1
Title
Email of person interviewed
example@example.com
Type of Business
Individual
Partnership
Corporation
LLC
Other
Years in business
More than 10 years
3 to 10 years
Less than 3 years
Years at current location
Management experience (in years)
More than 10 years
3 to 10 years
Less than 3 years
Number of company owners
Number of owners active in daily operations
USL&H Exposure?
Yes
No
Description of USL&H exposures
Loss Analysis
Workers Compensation claims in last 5 years
Yes
No
Description of past workers comp claims. Description should include type of injuries by year, trends, and corrective action taken to reduce/prevent similar claims . If no corrective actions, recs should be submitted.
OSHA fines/citations in the last 5 years
Yes
No
Description of OSHA Fines/Citations in the last 5 years.
OSHA Required records maintained
Yes
No
N/A (less than 10 employees)
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Operations and Management
Description of operations
Dedicated safety employee
Yes
No
What is the percentage of subcontractor usage?
Subcontractor controls
Certificates of Insurance
Adequate limits
Hold harmless clause
PPE Required
Written contract
Approved list of contractors
Formalized program for selecting subs
None
Other
Are copies of COIs Maintained?
Yes
No
Are Uninsured subcontractors utilized?
Yes
No
What is the percentage of Uninsured Subcontractor Usage?
Description of Subcontractor Duties
Does the Insured operate as a Temporary Staffing Firm
Yes
No
Employee Demographics
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
0-10%
11%-20%
21%-50%
51%+
None
Average hourly rate
Less than $10
$10-$20
$20+
Annual Payroll (Please use ""N/A", "Unknown", or "Not Disclosed" if no annual payroll)
Employee activities/duties showing employee breakdown by job duty
Piece Work
Yes
No
Volunteer Labor
Yes
No
Employment Screening
Employee selection procedures
Union
Written Application
Interview
Reference Check
MVR Review
Criminal background check
Skills Testing
Physical exam
E-Verify
None
Other
Other Employee selection procedures
Drug/Alcohol testing program
Yes
No
Drug/Alcohol testing program scope (check all that apply)
Pre-Placement
Random
Annual
Post Accident
For Cause
Medical benefits provided?
Yes
No
Percent of medical benefits paid by company
Describe medical benefits program
Return to Work program
Yes
No
Please provide details
Safety Program
Formal written safety program
Yes
No
N/A (less than 10 employees)
Safety committee utilized
Yes
No
N/A (less than 10 employees)
Frequency of safety committee meetings
Weekly
Bi-weekly
Monthly
Bi-monthly
Quarterly
Semi-annual
Annual
Employee safety meetings
Yes
No
Frequency of safety committee meetings
Weekly
Bi-weekly
Monthly
Bi-monthly
Quarterly
Semi-annual
Annual
Meetings Documented
Yes
No
Is there a Progressive Disciplinary Program?
Yes
No
Safety Incentives?
Yes
No
Safety incentive description
Formal Accident investigation procedures
Yes
No
Does it include taking photos to document the accident/incident?
Yes
No
Does it include formal documentation and reporting?
Yes
No
Self inspections/ Safety inspections performed?
Yes
No
Do you have at least one medical provider that you direct employees to in the event of an injury?
Yes
No
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Hazard Control Assessment
Weight of Materials lifted manually
Up to 40 pounds
More than 40 pounds
Powered Industrial Trucks/ Forklifts in use
Yes
No
PIT/Forklift Operators trained/ certified
Yes
No
Flammable/Combustible/Hazardous materials on site
Type, quantity, storage, use, exposure potential
Excavations
Any excavation or trenching exposures?
Yes
No
Describe excavation exposures and controls
Does the policyholder perform municipal line work?
Yes
No
To what depth are trenching operations conducted?
< 6 Feet
> 6 Feet
N/A
Fall Protection
Work done at height
Yes
No
Ladder use
Yes
No
Ladder safety inspection
Yes
No
Fall Hazard Equipment Training Provided?
Yes
No
Fall Hazard Equipment Training Provided?
Yes
No
N/A
Testing and Repair/replacement program for fall arrest systems
Yes
No
N/A
If Roofing, are controlled access zones established per 1926.502 with adequate distance from edge of roof.
Yes
No
N/A
Fall Protection Comments
Respiratory Hazards
Respiratory hazards present?
Yes
No
Describe respiratory exposures
Is there a respiratory protection program (OSHA 1910.134- which includes fit testing, medical exam, correct equipment for exposures, cleaning & maintenance)?
Yes
No
When is respiratory exam done
At hire
Weekly
Monthly
Semi-monthly
Annual
Pre exposure
Post exposure
Is fit testing done for all respiratory equipment?
Yes
No
Is there a respiratory upkeep/replacement program?
Yes
No
Confined Space
Confined space exposure
Yes
No
Described confined space operations
Confined space permit in place in required
Yes
No
Heavy Equipment use
Do insured employees operate heavy equipment?
Yes
No
Describe heavy equipment used
Is the equipment
Owned
Leased
Rented
Borrowed
Are employees trained and/or certified in the operation of the heavy equipment used
Yes
No
Unknown
Describe who is available for the inspection and maintenance of heavy equipment operated by insured employees
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Auto Exposure Present
Yes
No
Any vehicles in fleet subject to DOT FMCSR
Yes
No
DOT Number
Vehicle types
Car
Van
Pickup Truck
Box Truck
Tractor/Trailer
Dump Truck
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/Trailer
Tractor/Trailer use description
Number of Dump Truck
Dump Truck use description
Vehicles used to transport more than two employees to any location
Yes
No
Radius of operations
0-50 miles
51-200 miles
Over 200 miles
Vehicles operated daily
Yes
No
Cellphone use policy
Yes
No
Seatbelt use policy
Yes
No
Driver selection controls
MVR at hire
MVR annually
Driver training
Formal criterion for acceptability
Road test
Remedial training
None
Vehicle maintenance procedures (check all that apply)
Preventative Care
Tire replacement program
ASE mechanics
Pre & Post Checklist
In-house mechanic
Outside vendor
Service documented
No formal maintenance policy
Hired/non owned auto exposure
Yes
No
Describe hired/non owned auto exposure and controls
Hired and non owned controls in place?
Check valid Driver License
MVR review
Proof of Insurance
Vehicle Maintenance required
No Controls in Place
Opinion of risk
Above Average
Average
Below Average
Opinion justification
Recommendations made
Yes
No
Submit
Should be Empty: