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THORN VALLEY ENTERPRISES
PUBLIC LIVERY 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) Drivers
(II) Narrative (V) Accident Reporting
(III) (a) Operations (VI) Premises
(III) (b) Vehicles (VII) General Remarks and Comments
(III) (c) Inspection, Repair & Maintenance (VIII) Driver File Review Summary
(I) RISK SUMMARY
ENGINEER OPINION Recommendation
PROGRAM ELEMENT Excels Good Avg. Fair Poor
Notes (see recommendations) Number
Management
Operations and Maintenance
Safety Management
Driver Selection
Driver Training
Driver Supervision
Accident Reporting
Total # of Recommendations
Critical Important Suggested Total
Number of Vehicles*:
0
Discuss any Critical Improvements that are required:
List major positive factors:
Overall management safety attitude:
Remarks:
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(II) NARRATIVE
Account Overview:
Operations:
Vehicles and Equipment:
Inspection, Repair and Maintenance:
Safety Management
Staffing and Personnel:
Driver, Hiring, Training and Supervision
Crash Countermeasures and Controls:
Safety & Compliance:
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(III) (a) OPERATIONS
1) Type of Service
Airport Hotel School Proms Weddings Other
% % % % % %
2) Customer Base
Corporate Private Non Profit Government Transit Authority Other
% % % % % %
3) Year Established/Incorporated:
4) Management History:
5) Description of Operation:
6) Radius of Operation: Local (0-50): % Intermediate (51-200) : % Long Distance (> 200): %
7) Cargo other than passengers, describe:
8) USDOT# (if applicable): If applicable, USDOT Rating: Date Last Compliance Review:
Yes No Comments
9) Written policy forbidding radar detectors
10) Vehicles operated 24 hours per day
11) Restrictions on driving & on-duty time
12) Vehicles governed, company speed limit
Remarks:
(III) (b) VEHICLES
1) Number of vehicles: Vans Station Wagons Limos Sedans
Owned by Insured
Leased from Others
Passenger Capacity
2) Stretch Limos: 6 Passengers 8 Passengers 10 Passengers 12 Passengers Other
3) Special Equipment: Passenger Lifts: Rear Side Ramps Hydraulic None
4) Equipment Modifications:
5) Safe storage of vehicles? Open Lot Fenced Lot Covered.
6) If covered, how many in facility at one time?
7) Vehicles kept at drivers’ homes? Yes No If yes, who, what, why and when?
8) Public Protection City Police County Police Other:
9) Use of older equipment (over 10 years)
10) Appearance of Fleet Good Needs Improving Poor
11) Are any classic or antique automobiles used in the fleet? Yes No
12) Does the company purchase Used vehicles? Yes No
13) Does the company overhaul or rebuild its vehicles? Yes No
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14) Are vehicle equipped with any emergency equipment? (Extinguisher, triangles, flares, flashlight, etc.)? Yes No
15) Seat belts for occupants; Yes No
Remarks:
(III) (c) INSPECTION, REPAIR & MAINTENANCE
1) Vehicle maintenance Outside Garage Dealership Company
2) Who maintains maintenance records?
3) Are vehicle maintenance records maintained adequately? Yes No If no, explain:
4) Are daily vehicle condition reports completed by drivers? Yes No
5) Vehicle replacement schedule/program:
Remarks:
(IV) DRIVERS
1) Total number of drivers: Full-time Part-time Any family drivers:
2) New hires last 12 months % of turnover:
3) Independents used: Yes No If yes, describe:
4) Uniformed: Yes No If yes, describe:
5) Assist passengers; Yes No. If yes, describe:
6) Bilingual: Yes No. If yes, describe:
7) Commercial driver selection procedure: Yes No Comments
a) Standard Employment Application
b) Standard Physicals
c) Drug and Alcohol Testing
d) Reference/Past Employers
e) Experience
f) Written/Road Test
g) Interviews
h) MVRs Obtained
8) How are drivers compensated?
9) Supervision methods: Ride Check Road Observation Two Way Radio Computer Cell Phone
10) Number of drivers under 21 ; over 65
11) Driver orientation upon employment Yes No Comments
a) Company rules and policies Yes No
b) Commercial vehicle rules and regulations
c) Vehicle inspection procedures
d) Emergency procedures Yes No
e) CPR Training
f) Accident reporting procedures
g) Loading and unloading of passengers
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h) Lift equipment usage and familiarization
i) Route review and familiarization
j) Is a progressive disciplinary plan in place?
12) What type of remedial training provided?
13) Formal driver meetings held? Yes No
Remarks:
(V) ACCIDENT REPORTING
1) How many accidents current policy period;
2) Last policy period:
3) Number of fatal crashes in past 3 years;
4) Number of occupant bodily injury claims in past 3 years;
5) Collisions preventability determination: Yes No Parameters:
Remarks:
(VI) PREMISES
1) Age/Condition of Facilities: Good Average Fair Poor
2) Inside City Limits: Yes No
3) Number of Buildings: Type: Frame Block/Brick Non Combustible Pre-engineered Steel Other
4) Neighborhood Type: Industrial Residential Suburban Rural Mercantile Urban Other
5) Neighborhood Status: Improving Stable Changing
6) Distance to nearest responding fire department:
7) Distance to nearest fire hydrant: feet; Fire Department: Paid Volunteer
8) Fire protection: Sprinkler System Fire Alarm Fire Extinguishers
9) Housekeeping: Good Average Fair Poor
10) General Public: Access Does Not Access
11) Floors, Sidewalks, Stairs Condition: Good Fair Poor Other
12) Parking Lot Condition: Good Fair Poor Other
13) Other Locations
Remarks:
(VII) GENERAL REMARKS AND COMMENTS
1)
2)
3)
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(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
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CODE S= SATISFACTORY I = INCOMPLETE M = MISSING
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