Landscaping - Industry Supplemental Questionnaire
Applicant Information:
Proposed Effective Date: / /
Legal Name:
Application ID:
Application completed by: Broker: Employer:
Please provide (first, last) name: ______________________________ Date: _____________________________
General C
lassification Evaluation:
1) Maximum Height exposure (including tree trimming, if applicable): _____Ft. N/A
If applicable - Method of reaching height exposures: (Check all that apply)
Ladder Scaffolding Scissor Lifts Other: __________
If scaffolding is used, does the insured build their own? No Yes - _____% of annual operations compared to total operations.
2) Maximum Weight lifted: _____lbs. N/A
If applicable: Manual Lifting Employee(s) lifts with assistance: Please explain: _____________________
Please list the typical types of items lifted: _______________________________________________________
3) Vehicle exposure: Yes No
If Yes
Percentage of total operations: _____% Total # of Vehicles_____
Number of employee drivers: _____ Do employees take the vehicle home overnight? Yes No
Driving Radius in miles: _____mi. GPS tracking system installed? Yes No
MVR’s Checked: Yes No Company Owned: Yes No
PUC Filing: N/A
Yes: __________ MCP Filing: N/A Yes: __________
4) Any Out of State, International, or Overnight Travel: Yes No
If Yes - Please provide:
Number of employee’s traveling: ____
Method of transportation: __________________ Location(s): _______________________________
Frequency of travel: _______________________ _______________________________
5) CPR Training provided: Yes No If Yes - Number of Employees certified: _____
Claims Ha
1) Is there a set procedure for reporting claims? Yes No
2) Is there a formal written accident investigation report? Yes No
3) Do you currently participate in an MPN program to control claim costs? Yes No
Please describe the type of landscaping services performed:
(i.e. Sprinkler installation, Erosion Control Excavation or trenching work, etc.)
[Text Here]
Please list any equipment used (including tree trimming equipment):
Percentage of operations: Residential___% Commercial___% =100%
Percentage of operations: Mow/Blow ___% Landscape Design ___% =100%
Do the operations include snow removal: Yes
If yes, do the operations include snow removal from rooftops? Yes No
Do the operations include Tree Trimming: No Yes ____% of operations
Does the insur
ed perform hardscape work? Yes
If yes, please explain:
[Text Here]
Does the insured hire day laborers? Yes No
Any Highway, Curbside, or Road Median work performed? Yes No
If yes; what is the percentage of the total operations? _____%
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Personnel P
1) New-hire orientation program: Yes No Is the orientation documented? Yes No
2) Owner is active in daily operations: Yes No
3) Employee Handbook: Yes No
4) Post-accident drug testing: Yes No
5) Job specific training: Yes No
6) Performance Appraisals: Yes No
7) Wellness program in place: Yes No
8) Are any of the following benefits provided?
Medical: No Yes: Employer contribution: ____% Percentage of employees enrolled: ____%
Retirement: No
Yes: Employer contribution: ____% Percentage of employees enrolled: ____%
9) Any other information in regard to employee benefits? If so, please provide those details:
Employer-Employee Relationship:
1) Employee Turnover Rate (Annually): ____% Average Tenure of Employees (in # of years): _______
2) Number of employees hired:
Full Time (annual): ____ Payroll Estimate: $_______
Part Time/Seasonal: ____ Payroll Estimate: $_______
No. of seasonal Employees: _____
Seasonal Employee Period (From Month: _________ to Month: ________)
Safety Program/Practices which are implemented and enforced:
1) Fall Protection Plan: Yes No N/A
2) Heat and illness prevention program: Yes No N/A
3) Respiratory program: Yes No N/A
4) Driver safety training plan: Yes No N/A
5) Forklift training & safety plan: Yes No N/A
If Yes Annual Certification required: Yes No N/A
6) MSDS available for all chemicals/products used: Yes No N/A
7) Written Lockout/Tag out/Block out Procedures: Yes No N/A
8) Hazardous chemicals safety plan: Yes No N/A
9) Confined spaces plan: Yes No N/A
10) Active safety incentive program for all employees: Yes No N/A
11) Are supervisors held accountable for a safe work environment? Yes No N/A
12) Extreme temperature program meets Cal OSHA Requirements: Yes No N/A
13) Is there a dedicated full time safety manager? Yes No N/A
If Yes Please provide:
Name: __________________________________ Title: __________________________________
14) Safety meetings are conducted: Daily Weekly Monthly Quarterly Does not conduct Safety Meetings
Are safety meetings documented? Yes No
15) Personal Protective equipment provide to all employees: No Yes, please list types: ________________________________________________
16) Employee to Supervisor ratio: _____ / _____
17) What loss prevention recommendations has the insured implemented? Loss control service has not been performed.
ry and Equipment:
1) Please list the types of machinery/equipment used: ______________________________________________________________ N/A
2) Are all equipment operators certified? Yes No
3) Is all machinery/equipment properly guarded: Yes No
4) Age of equipment in years: 0-5 5-10 10-20 20+
5) Condition of the equipment: Excellent Good Average Poor
6) Who is responsible for maintaining machinery? Insured Contractor Other: ________________________
Is there any other information about your company, operations, or practices you have implemented which could have an impact
on mitigating injuries?
Year implemented: __________
[Text here]
e10337 (New 3/20)
© State Compensation Insurance Fund
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