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THORN VALLEY ENTERPRISES
COMMERCIAL VEHICLE 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 (IV) Safety Management
(I) (a) Narrative (V) Driver Selection
(II) Account Overview (VI) Driver Safety Training
(III) (a) Operations (VII) Driver Supervision
(b) Vehicles (VIII) Accident Reporting
(c) Inspection, Repair & Maintenance (IX) Premises
(d) Owner/Operators (X) Notes
(e) Cargo & Hazmat (XI) Driver File Review Summary
(I) RISK SUMMARY
ENGINEER OPINION Recom- C*
PROGRAM ELEMENT Notes (see recommendations) mendation I*
Excels Good Avg Fair Poor Number S*
Management
Operations
Maintenance
Safety Management
Driver Selection
Driver Training
Driver Supervision
Accident Reporting
Total Fleet Size Total # of Recommendations
*Critical *Important *Suggested Total
Number of Power Units: # Trailers:
0
Discuss any Critical Recommendations that are required:
List major positive factors:
Overall management safety attitude:
Remarks:
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 1 of 8
(I) (a) NARRATIVE
Account Overview:
Operations:
Vehicles and Equipment:
Inspection, Repair and Maintenance:
Safety Management
Staffing and Personnel:
Driver Selection, Hiring and Orientation:
Driver Safety Training and Awards Program:
Driver Supervision:
Crash Countermeasures and Controls:
DOT Compliance:
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 2 of 8
(II) ACCOUNT OVERVIEW
1) Type of Organization: Corporation Partnership Sole Proprietorship LLC
2) Years in Business: Years under current management:
3) If < 2 yrs, describe management qualifications:
4) US DOT#: MC#: Other regulatory identifications:
5) USDOT Safety Rating: Satisfactory Conditional Unsatisfactory Most recent rating date:
6) Out of Service % (Check if > Nat’l Avg.): Vehicle % Driver % HAZMAT %
7) Carrier Safety Management (SMS) BASICs On-Road Investigation “Alert” Status
Unsafe Driving
Fatigued Driving
Driver Fitness
Controlled Substances & Alcohol
Vehicle Maintenance
Cargo Related
Total Crashes Tow away Injury/Fatality
8) Are BASIC scores trending Up or Down?
9) Gross Receipts Dollars Fleet Miles Revenue/Mile
Rev/Mi in normal Guidelines:
Current Year (Est) $ $ Yes No
If no, please include Remarks.
Prior Year $ $
10) Significant company changes past 12 months:
11) Number of power units added or deleted in past 12 months: Explain:
Remarks:
(III) (a) OPERATIONS
Van Reefer Flatbed Tanker Container Bulk Dump Other Total
% % % % % % % % 0%
Radius: 0-50 Miles 50-200 Miles 201 – 500 Miles 501+ Miles Total
% % % % 0%
1) Average number of power units on the road on any given day:
2) Hrs of Operation Trucks: Office: Garage: Dispatch:
3) Average Trip Length One Way: Number of days drivers are normally out:
4) Large Metro Areas and % delivered to:
5) Large Metro Areas and % driven through:
6) Percent Mountain Driving: % Percent Night Driving: %
7) Carrier Type: For-Hire Common Contract Private Service Use Retail Delivery
Irregular Route Regular Route Private Other
8) Percent LTL Freight: % Percentage JIT Freight: %
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 3 of 8
9) On Premise Activity Other than Trucking: Yes No Remarks:
10) Brokerage Operation: Yes No MC/DOT # of brokerage: (Note: Request copy of brokerage insurance policy)
11) Revenue from Brokerage: Number of Brokered Loads per Week:
12) Long Term Equipment Leasing to Others: Yes No Remarks:
13) Owner/operators: Yes No Length of Lease:
14) O/O Lease Renewal Date: Automatically Renews: Yes No
15) Bobtail Insurance Required: Yes No Amount: $ Named as additional insured: Yes No
16) Backhauls: Yes No Company Freight: % Brokered Freight: % Deadhead: %
17) Auth. Passengers Allowed: Yes No (Note: Request copy of passenger insurance policy)
18) Passenger Identities: Hold Harmless/Release: Yes No Expires:
Remarks:
(b) VEHICLES
POWER UNITS TRACTOR STRAIGHT TK SERVICE TK DUMP OTHER
1) Company
2) Owner/OP
3) Short Term Lease
TRAILERS VAN REEFER FLAT TANK CHASSIS DUMP BULK DOUBLE
4) Company
5) Owner/OP
6) Short Term Lease
7) Number of Units Subject to a Single Loss:
Remarks:
(c) INSPECTION, REPAIR & MAINTENANCE
1) Oldest Vehicle in Fleet: Number Vehicles this Age: Scheduled Fleet Update Plan Yes No
2) Equipment in Fleet > Ten Years Old: Yes No How Many:
3) Preventive maintenance intervals:
4) Condition of Equipment on Yard:
5) Unusual Equipment:
6) Maintenance performed by: Company Vendor
7) Maintenance records maintained by: Company Vendor
8) Safety Inspection Lane: Yes No Driver Inspections completed and documented: Yes No
Remarks:
(d) OWNER/OPERATORS
1) Restriction on Age of Owner Operator Vehicles: Yes No Describe:
2) Tractor Garaging Location: Company Owner/Operator Other:
3) O/O Maintenance performed by: Owner/Operator Company Vendor Name:
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 4 of 8
4) O/O Maintenance records maintained by: Owner/Operator Company Vendor Name:
5) O/O equipment inspected by company: Yes No Frequency:
6) Preventive maintenance intervals:
7) Safety Inspection Lane: Yes No Driver Inspections completed and documented: Yes No
Remarks:
(e) CARGO & HAZMAT
1) Cargo Description:
2) Oversize/Overweight: Yes No Length: Height: Weight: Percent of Total Haul:
3) Hazardous Materials: Yes No Hazardous Waste: Yes No Type:
4) Does Safer list Hazmat Authority or any Hazmat Inspections? Yes No Type:
HAZMAT TYPE CLASS TRADE NAMES PERCENT of LOAD
Remarks:
(IV) SAFETY MANAGEMENT
1) Safety Department: Yes No F/T Safety Director: Yes No Name:
2) Safety Manager Certified/Trained: Yes No Courses:
3) Written Safety Policy: Yes No Driver Manual: Yes No Driver Acknowledgement: Yes No
4) Defensive driving provided as part of orientation: Yes No
5) Driver Safety Awards Program: Yes No Other safety incentive programs: Yes No
6) Company/Management has received Safety Award(s) or Recognition: Yes No Describe:
Remarks:
(V) DRIVER SELECTION
Full Time Part Time Team Owner/Operator Total
1) # Drivers
0
2) Number of Drivers Under 24: Over 65:
3) Number of Drivers Hired Last 12 Months: Percent Turnover Last 12 Months: %
4) Written Hiring Criteria: Yes No Minimum: Age: Experience:
5) Maximum Allowable: Convictions: Collisions: Jobs:
6) Exceptions to these requirements: Yes No Who and When:
7) # Prior year(s) background checked: 1 yr 2 yr 3 yr 4 yr 5 yr 6 yr More:
8) Prior employment checks completed before first dispatch: Yes No
9) Who interviews new drivers? Describe interview process
10) Road Test: Yes No Number of miles: Administered by:
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 5 of 8
11) Probation period for new drivers: Yes No Describe:
12) Leased Drivers: Yes No DQ Files are at: Company Driver Leasing Firm Name of Firm:
13) Drug & Alcohol testing program: Yes No Program Administrator:
14) DOT medicals current: Yes No Examining Physician designated by: Company Employee
15) Annual Reviews and MVR current: Yes No
16) Carrier utilizes Pre-Employment Screening Program (PSP): Yes No
17) DOT Compliance deficiencies:
Remarks:
(VI) DRIVER SAFETY TRAINING
1) Group safety meetings: Yes No Frequency: Attendance mandatory: Yes No
2) Meetings documented: Yes No Facilitator: Subject Matter:
3) Defensive Driving (DDC, Smith System, etc): Yes No Certificates issued for course completion: Yes No
4) Describe DDC training:
5) Re-occurring/Periodic training: Yes No Remedial training: Yes No
6) Describe Re-occurring/Remedial training:
7) Periodic Check rides? Yes No Number of miles: Administrator:
Remarks:
(VII) DRIVER SUPERVISION
1) Company uses road patrols or has a call in number for the public displayed on the trucks: Yes No
2) Trucks equipped with Qualcomm or similar devices: Yes No Policy for “No Use in Motion”: Yes No
3) Trucks equipped with speed governor: Yes No Maximum speed limit:
4) Drivers keep logs: Yes No If logs are not kept, other documentation used:
5) Formal log audit program: Yes No Log audit service or software: Yes No Type:
6) Name of person auditing logs: Person has formal training: Yes No Type:
7) Logs are checked for falsification: Yes No Supporting Docs: GPS Qualcomm ECM
Fuel receipts, tolls, etc Software (PC Miler, Rand McNally, etc.) Other:
8) Adequate Log Violation Disciplinary Program: Yes No
9) Dispatch maintains log recap: Yes No Other method used:
10) Daily driver check call: Yes No Penalty for late delivery: Yes No
Remarks:
(VIII) ACCIDENT REPORTING
Total # of Accidents DOT Recordable Register Current Comments
1) Current Yr Yes No
2) Prior Year Yes No
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 6 of 8
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:
(X) PREMISES
1) Neighborhood: Rural Suburban Urban Inner City Industrial Other:
2) Condition: Improving Stable Deteriorating
3) General Condition of Facility: Excellent Good Average Poor
4) Fenced main location: Yes No Security lighting: Yes No Recent theft or vandalism: Yes No
5) Other Locations or Terminals: Yes No Describe:
Remarks:
(X) GENERAL REMARKS AND COMMENTS
1)
2)
3)
4)
5)
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 7 of 8
(XI) Driver File Review Summary Form
Company Name:
Date:
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
CVLCS 04/2012 Commercial Vehicle Loss Control Survey Page 8 of 8
