2
Personnel P
ractices:
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.
Machine
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: __________
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e10337 (New 3/20)
© State Compensation Insurance Fund
