Risk Assessment Report

 

Account Name: {{7974-55a1-d7f2}} FEIN: {{a974-6a9d-392b}}
Address: {{e8b7-3d59-9915}}, {{6731-5ef9-47e3}} {{baed-9ba5-79d2}}, {{96ab-45d7-a573}}
Location Surveyed: {{56bf-d87c-8496}}
Contacts: {{5daa-9f9c-0c56}} {{2814-701a-2c8d}} Phone: {{abdd-99bc-812b}}
Email Address: {{71ef-7c2a-5f18}}
Date of Visit: {{8b34-a156-dd64}} Date of Next Visit: {{8f14-c368-d6d9}}
Premium Level: {{6696-ee3d-1c24}}
Loss Control Rep: {{7521-7382-6288}}

Purpose of Loss Prevention Visit: {{a61d-9eaf-1820}}

If Purpose is "Other," please describe: {{58b8-c0dc-495d}}

Description of Operations: (type of business, ownership, years in operation, size, anticipated growth/downsizing, ancillary operations, other locations, etc.)

{{b80e-4b80-caa5}}
 
Account Name: {{7974-55a1-d7f2}} Date of Visit: {{4cec-d328-5f1c}}

 

EMPLOYEE DATA: Comments:
Number of Employees: Full-Time: {{cdac-900c-73ad}} Part-Time: {{3bac-cde8-4b49}} Seasonal: {{894f-6c60-584b}}
Any H2A Employees? {{756f-e0ea-1609}} Describe: {{f98c-2fbd-2857}}
Avg. length of employment: {{d999-f326-6d5c}}
Employees under age 16? {{2b97-87d8-85ff}} {{f385-a45e-2909}}
Housing Provided? {{4bf7-ea37-c73d}} {{a4af-df20-1ddb}}

 

1. HIRING AND TRAINING PRACTICES Comments:
Written Application Used: {{ccee-74e4-6100}} {{33dc-5601-e0ec}}
Job Description with Physical Demands: {{1cc4-e161-267b}} {{5e93-a182-7b3f}}
Interviews Completed: {{fa87-3919-6873}} {{23f7-8ca2-d51c}}
Screening Procedures: {{2ac0-f426-e34f}} {{7af4-64e7-8420}}
New Hire Orientation / Training prior to working the position: {{e4c0-de8c-04c2}} TODO: {{6f52-6fda-aa2e}},{{c0ea-6647-8cb5}}
New Hire Orientation / Training Documented: {{dd41-46d8-ad4a}} {{8dcc-a737-0c63}}
SECTION RATING/SCORE {{0c06-1181-ddc2}} 4-Excellent, 3-Good, 2-Fair, 1-Poor

 

2. SAFETY MANAGEMENT Comments:
Safety Program in place {{1302-d777-2692}} {{3eee-9bde-3049}}
Safety Rules clearly communicated {{77d6-98e2-3761}} {{0e84-d2b1-e673}}
Periodic Safety Training: {{7d02-7200-f798}} {{0e84-d2b1-e673}}{{d5a4-faf9-ca59}}
Employee Orientation / Training when switching job/position: {{83ff-69b3-1a2f}} {{f885-dcba-61d5}}{{2eb2-cdd2-eaa7}}
Remedial Employee Training: {{2ae5-1296-cabb}} {{fd21-4fdf-c3c7}}
Safety training documented {{723f-7f8b-7692}} {{52fe-ea1f-99f5}}
Safety compliance promoted / enforced {{2671-fa13-4b31}} {{fd63-bd03-7550}}
Periodic Safety Inspections: {{6f5b-58ba-5f4e}} {{4c22-56db-062b}}{{3843-2ce8-550e}}
Employees instructed to report all Accidents and “near misses” {{5360-021a-6c03}} {{3071-21f4-934a}}
All Accidents investigated by Management {{b9e4-4186-030c}} {{a949-3134-9988}}
Corrective Actions implemented and reviewed with employees {{72c0-8261-5881}} {{8817-f249-694c}}
Return to Work Program {{ad17-c147-5ac2}} {{e351-5668-8cbe}}
Medical providers identified {{ed1f-b308-a4a5}} {{4791-10d6-8625}}
First Aid Supplies on site {{5d48-c2d3-a6af}} {{00a1-d2fc-7c38}}
CPR & First Aid training {{7a72-c0fc-b11f}} {{1c76-2a94-d05a}}
Emergency Action Plan {{068a-28ff-524e}} {{edd0-71f6-a1b3}}
Fire Dept. or other First Responders visited farm {{a739-7649-8527}} {{d62c-94f6-d690}}
SECTION RATING/SCORE {{0daf-a7e9-0a6b}} 4-Excellent, 3-Good, 2-Fair, 1-Poor

 

3. OPERATIONAL EXPOSURES AND CONTROLS Comments:
Tractor / Equipment Operators trained/qualified {{8052-e3c0-cfa4}} {{ae71-c2a7-c9b9}}
Tractor and Equipment exposures controlled {{bda8-7b13-2430}} {{f1b4-5d89-1922}}
ATVs used by Employees {{6f44-01db-8d6b}} {{0772-58c2-a045}}
Animal Handling exposures controlled {{478b-6b21-d59a}} {{3d1d-c196-d241}}
Walking/Working Surfaces in Good Condition {{3d44-5a83-e0ff}} {{450c-aa0d-aef3}}
Housekeeping & Life Safety controls adequate {{6167-829a-33e7}} {{d9a2-cfd8-7d6f}}
Any Work at Heights {{de43-b7d0-8d36}} {{4055-9d1a-0864}}
Electrical exposures controlled? {{e8ee-8a2b-e8eb}} {{7b53-b163-b456}}
Lock Out / Tag Out program {{f277-eba5-b6e7}} {{0d8c-5e1e-3c31}}
Machine guards in place {{f2ca-f005-ddce}} {{49b0-9f39-0c66}}
Confined Spaces Identified / Signage Posted {{36bb-c48d-1d59}} {{f3d6-0ea5-eda4}}
Confined Space Entry Program {{9ef9-8a3c-a986}} {{a788-1903-ff73}}
Manual Material Handling Controls Adequate: {{da2b-b258-56b2}} {{180c-c388-39af}}
Chemical handling exposures controlled {{d0cd-54ac-3459}} {{ca74-2276-8e2b}}
Safety Data Sheets (SDS) readily available {{4461-8497-1487}} {{b440-18f3-ad3a}}
Annual Haz Comm training {{f71d-4a4f-a5d9}} {{bc00-f776-aaa4}}
Appropriate PPE provided, and use required {{beab-913b-fd45}} {{d9dd-e17e-10b2}}
Maintenance/repair shop exposures controlled {{74d6-74ec-d604}} {{c0aa-714f-a093}}
Flammable Liquids {{39a4-c2d8-86bc}} {{1072-67f7-d0e2}} {{b7c3-c3fe-7711}}
Adequate Fire Extinguishers available {{06e4-9166-d42a}} {{5223-60c3-b741}}
Manure Lagoons/Pits adequately protected, and Warning Signs posted {{ebef-bc52-5707}} {{eda8-09bb-3607}}
Silage piles properly faced {{e0a1-dc99-1c1b}} {{919d-010a-fea7}}
Access Restricted at Silage face and load out areas {{b81b-82dd-7f9f}} {{eb4c-397d-3aa1}}
Noise exposures controlled {{81ed-0c3c-fe38}} {{9033-5453-9354}}
Other Specific Risk exposures/controls {{71ae-f694-cf69}} {{3c83-7ae8-8271}}
SECTION RATING/SCORE {{9cde-2d97-b757}} 4-Excellent, 3-Good, 2-Fair, 1-Poor

 

4. SUBCONTRACTORS Comments:
Subcontractors Used: {{c25f-75f9-5ec5}} {{49c3-d72a-9698}}
Certificates of Insurance Obtained for WC: {{1267-eaf0-e7f2}} {{b4eb-4dd5-aad5}}
Certificates of General Liability insurance required from all subs: {{d14b-d95d-0e8e}} {{479d-bc99-eec9}}
Additional Insured Status Required: {{568d-2d19-2a65}} {{0123-ffab-5015}}
SECTION RATING/SCORE {{0522-bec4-f313}} 4-Excellent, 3-Good, 2-Fair, 1-Poor

 

5. VEHICLE EXPOSURES Comments:
Employees operate Company Vehicles: {{2434-ca28-d9ac}} {{4381-9ee8-8b51}}
Employer-provided transportation for Employees {{0c65-9823-de0e}} {{8ef6-12a5-2679}}
MVRs obtained and reviewed annually for all drivers {{75be-37ac-c104}} {{a4d9-06ae-c725}}
Distracted driver policy {{8c34-d60f-d227}} {{7c2a-931f-5894}}
Vehicles surveyed in good condition {{c6bd-9d7d-603a}} {{f17e-af73-612d}}
Additional Comments: {{8b08-6e55-78b0}}
SECTION RATING/SCORE {{5be8-1d5d-3587}} 4-Excellent, 3-Good, 2-Fair, 1-Poor

 

6. LOSS HISTORY / ANALYSIS Comments:
Loss History reviewed with Account Contact: {{b581-ccf9-96d4}} {{a619-f08f-bf46}}
Loss Trends Identified {{c4e6-8dab-3a77}} {{5662-df2e-e83e}}
Corrective Actions taken by Account to address Loss Leaders {{b402-d177-0a21}} {{7526-ab28-5c41}}
Additional Comments: (Favorable/Unfavorable loss history) {{9b29-ce22-4010}}
SECTION RATING/SCORE {{6e72-c941-b05e}} 4-Excellent, 3-Good, 2-Fair, 1-Poor
 
Account Name: {{7974-55a1-d7f2}} Date of Visit: {{4cec-d328-5f1c}}

 

LOSS CONTROL CONCLUSION
Section Score
Hiring / Training Practices {{0c06-1181-ddc2}}
Safety Management {{0daf-a7e9-0a6b}}
Operational Exposures and Controls {{9cde-2d97-b757}}
Subcontractors {{0522-bec4-f313}}
Vehicle Exposures {{5be8-1d5d-3587}}
Loss History / Analysis {{6e72-c941-b05e}}
Calculated Score / Rating

 
Consultant Score / Rating {{717c-e5e9-0499}}
 
Account Name: {{7974-55a1-d7f2}} Date of Visit: {{4cec-d328-5f1c}}

 

{{formyoula_repeat_daee-9c8b-3c06}}

{{6df7-ebb2-b6e0}}

Description:
{{08a7-e8fd-322d}}

 

{{formyoula_repeat_daee-9c8b-3c06}}

 

This report was developed solely for underwriting purposes. Agri-Services Agency, its affiliates, agents, brokers and employees assume no responsibility for the discovery and elimination of hazards which could cause accidents or loss. This Report is for internal use only. It should not be distributed to any third party.