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THORN VALLEY ENTERPRISES
RENTAL COMPANY LOSS CONTROL SURVEY
Insured Date
Address Policy Number
City, State Zip Loss Control Engineer
Person(s) Interviewed Overall Opinion of Risk
Title(s) E-mail address
Phone Number Agent
TABLE of CONTENTS
(I) Risk Summary & Narrative (IV) Driver Safety
(II) Account Overview (V) Accident Reporting
(III) (a) Rental Operations (VI) Premises
(III) (b) Vehicles (VII) Comments and General Remarks
III (c) Cargo - Commodity (VIII) Employee/Driver File Review
(I) RISK SUMMARY
ENGINEER OPINION Recommendation
PROGRAM ELEMENT Excels Good Avg. Fair Poor Notes (see recommendations) Number
Management
Operations and Maintenance
Safety Management
Driver Safety
Cargo - Commodity
Accident History
Total # of Recommendations
Critical Important Suggested Total
Number of Vehicles:
0
Discuss any Critical Recommendations that are required:
List major positive factors:
Overall management safety attitude:
Remarks:
RCLCS 07/12/2011 Rental Operation Loss Control Survey Page 1 of 7
(I) (a) NARRATIVE
Account Overview:
Rental Operations:
Vehicles and Equipment:
Inspection, Repair and Maintenance:
Safety Management
Staffing and Personnel:
Driver, Hiring, Training and Supervision
Crash Countermeasures and Controls:
Safety & Compliance:
RCLCS 07/12/2011 Rental Operation Loss Control Survey Page 2 of 7
(II) ACCOUNT OVERVIEW
1) Type of Organization: Corporation Partnership Sole Proprietorship LLC
2) Franchise Location Company Location Parent Company
3) Years in Business: Years under current management:
4) If < 2 yrs, describe management qualifications:
5) US DOT#: N/A Other regulatory identifications:
6) USDOT Safety Rating: N/A Not Rated Satisfactory Conditional Unsatisfactory
7) Description of Operations:
8) Significant company changes past 12 months:
9) Number of power units added or deleted in past 12 months: Explain:
Remarks:
(III) (a) RENTAL OPERATIONS
1) Rentals/Leases: < 30 days > 30 days Auto Passenger Truck Tractor Trailer
2) Clientele: Consumer % Business % Insurance % Govt. Agency % Other %
3) Rental counter: Yes No Location(s):
4) Rental counters accept cash: Yes No Floor safe: Yes No Security camera: Yes No
5) Daily rental vehicle inventory taken: Yes No Remarks:
6) Pickup and delivery: Yes No Location(s):
7) Hours of Operation: Rental Counter Office Shop
8) # of Company Drivers: Rental Office Shop Hikers Other
9) Authorized Passengers allowed with Company Driver: Yes No Passengers name(s):
10) Passenger Hold Harmless or Release Obtained: Yes No
11) Transfer Company(s) used: Yes No Name(s)
12) Transfer Company(s) insurance certificate on file: Yes No Copies provided: Yes No
13) Percentage of Rentals In: 0-50 Miles % 50-200 Miles % 200+ Miles % Unknown
14) Percentage of Interstate Rentals: % Unknown
15) Areas/Sates Travelled: Unknown
16) Foreign Operations: Canada Mi/Yr/Province Mexico Mi/Yr/State
17) Average Short Term Rental: # Days # Miles Unknown
18) Commercial Rentals: Private % For-hire % Service % Retail % Other: %
19) Top Commercial Customers:
20) Commercial accounts may opt to provide own liability and/or PD coverage: Yes No
21) Customer-Provides Insurance (CPI) certificates on file: Yes No Customer name(s):
22) CPI certificates name Risk as Additional Insured and Loss Payee: Yes No
23) Commercial account USDOT # recorded on short term CMV rental contracts: Yes No
Remarks:
RCLCS 07/12/2011 Rental Operation Loss Control Survey Page 3 of 7
III (b) VEHICLES
AUTOMOBILE
ECONOMY COMPACT INTERMMEDIATE STANDARD FULL SIZE PREMIUM LUXURY
VANS and PICKUPS
MINIVAN SMALL SVU STANDARD SVU LARGE SVU PICKUP PANEL VAN CARGO VAN
TRUCKS and TRAILEERS
BOX VAN FLATBED STAKE BED TRACTOR VAN TRLR REEFER CAR TRAILER
1) Other Vehicle Types:
2) Any Unusual Equipment:
3) Oldest Vehicle in Fleet: Number of Vehicles this Age:
4) Scheduled Fleet Update Plan:
5) Any Vehicles > Ten Years Old: How Many:
6) Verify inspection/maintenance on units > 10 yrs. old:
7) Condition of Equipment on Yard:
8) Documented damage out/in inspection for each rental: Yes No Describe:
9) Trucks between 10,001 and 26,000 lbs. rented to individuals for moving furniture: Yes No N/A
10) Accessory Equipment Rental (hand truck, furniture pads, moving supplies) Yes No Type:
11) Maintenance on rental vehicles performed by:
12) Inspection intervals:
13) Records kept by:
14) Mobile Service Unit(s): Yes No Describe service:
15) Maintenance-Only Leases: Yes No Vehicle Types & Service Performed:
16) Finance Leases: Yes No Vehicle Type & Finance Company:
Remarks:
III (c) CARGO - COMMODITY
1) Passenger transport rental vehicles: Yes No Type & Capacity (including driver):
2) Consumer household furniture: Yes No Pack & Load Service: Yes No
3) Automobiles permitted in van truck or trailer: Yes No Comments:
4) Car trailers: Yes No Car dollies: Yes No Tow bars: Yes No Hookup provided: Yes No
5) Hazmat permitted: Yes No Type:
17) Unusual Cargo (boats, sheds, over dimensional, etc):
Remarks:
RCLCS 07/12/2011 Rental Operation Loss Control Survey Page 4 of 7
(IV) DRIVER SAFETY
1) Safety awareness posters and communications in rental area: Yes No. Describe:
2) Rental Driver Qualification
A) License verified (copied for commercial vehicles) Yes No
B) Physicals verified (commercial drivers only) Yes No
C) Credit card required (non billing accounts) Yes No
D) After hours rental contracts left with shop Yes No
E) Renter instructed on vehicle operation Yes No
F) # & type of drivers contractually limited Yes No
G) Drivers < 21 years old allowed Yes No
H) Accident & Emergency procedures explained Yes No
4) Driver Qualification File for company employee/drivers of Commercial Vehicles: Yes No Remarks:
5) Company has a full time safety manager: Yes No Remarks:
6) Company offers safety services to customers: Yes No Remarks:
7) Formal safety meetings held: Yes No
Remarks:
(V) ACCIDENT REPORTING
Total # of Accidents DOT Recordable Register Current Comments
1) Current Yr Yes No
2) Prior Year Yes No
3) Record kept of all accidents, including non-DOT: Yes No Periodic accident trend analysis: Yes No
4) Name of person tracking accidents: Has received formal training: Yes No
5) Recent counter-measures taken in response to accidents or accident trends:
6) Preventability determined: Yes No Preventability Guide: Yes No
7) What remedial actions are taken when a driver has an accident?
Remarks
(VI) PREMISES
1) Neighborhood: Rural Suburban Urban Inner City Industrial Other
2) Condition: Improving Stable Deteriorating
3) General Condition of Facility: Good Average Poor
4) Fenced at Main Location:
5) Other Locations or Terminals:
6) Fenced Yard:
7) Public Protection:
8) Rental vehicle keys secured: Yes No Describe:
RCLCS 07/12/2011 Rental Operation Loss Control Survey Page 5 of 7
9) After hours key drop off: : Yes No Describe:
10) Recent Thefts or Vandalism:
Remarks:
(VII) GENERAL REMARKS AND COMMENTS
1)
2)
3)
4)
5)
RCLCS 07/12/2011 Rental Operation Loss Control Survey Page 6 of 7
(VII) Employee/Driver File Review Summary Form
Company Name:
Date:
Note: only review Company Employee/Drivers (not rental drivers)
Employment Date CDL Date Driver Violations
Driver Name Application Reference of MVR CDL Endorse of Annual Data
date Inquiry Birth Date Class -ment Physical Review Sheet Speed Moving Non Moving
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
CODE S= SATISFACTORY I = INCOMPLETE M = MISSING
RCLCS 07/12/2011 Rental Operation Loss Control Survey Page 7 of 7
