Insurance Loss Control Survey Form
Use this form to document a property loss control review, note observed hazards, and rate key safety and protection practices.
Survey Details
Respondent Name
*
First Name
Last Name
Company Name
*
Property/Site Address
*
Primary Property Type
Office
Retail
Warehouse
Manufacturing
Multi-family
Other
Approximate Square Footage
*
Survey Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Loss Control Assessment
Housekeeping / Organization
*
1
2
3
4
5
Fire Protection
*
1
2
3
4
5
Electrical Safety
*
1
2
3
4
5
Storage / Material Handling
*
1
2
3
4
5
Slip / Trip / Fall Prevention
*
1
2
3
4
5
Security / Access Control
*
1
2
3
4
5
Hazards and Improvements
Observed Hazards or Concerns
*
Blocked exits
Flammable storage
Poor lighting
Damaged flooring
Exposed wiring
Missing extinguishers
Inadequate housekeeping
Unsecured access
Other
Additional Notes or Corrective Actions Planned
Overall Risk Level
*
Low
Moderate
High
Submit Survey
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