Lancer Insurance Company

DC White Vendors Safety Evaluation

Account Name:
Address: / ,
Location Visited (If Different from Address):
Contact Type: / Telephone PhysicalVisit
Client Number: / Policy Number: / Link Number:
Client Contact Name & Title:
Surveyed By: / Gardner Group / Inspector Name:
Survey Date:
Report Completion Date:
Client Phone No.: / () - / Email Address: / N/A / Fax No.: / ()
GENERAL FINDINGS
Acceptable / Acceptable with Recommendations / Not Acceptable / N/A
Management Procedures
Management Interest
Driver Selection Procedures
Supervision Adequacy
Facilities
Equipment Condition
Maintenance Program
RECOMMENDATIONS (DCW USE ONLY)
Letter Type: LIL2L3L4L5L6L8P1P2P3P4P5 / Requirements:
Recommendations:
Grade Number 12345678 Address to:
Value Added Material Left: No Yes

FOLLOW UP

Why was visit made? / Audit Follow-up Claims Growth Prospect Other:
Follow up visit requested? / Yes No
Time Frame? / 30 Days 60 Days Other:

DC White Vendors Safety Evaluation (09-07)Page 1 of 4

GARAGE LIABILITY SECTION
Coverage Type: / Dealer / Non-Dealer / GKLL
Dealer Phys Dam / Other (Describe)::
OPERATIONS OF INSURED
(check all that apply)
Service Station (Gas Only) / Valet Parking
Service Station (Repair Only) / Towing Service
Service Station (Gas and Repair) / Car Wash
Body Shop / Used Car Dealer
Parking Garage / New Car Dealer
Parking Lot / Tire Shop
Convenience Store / Customer Pick-Up/Delivery
Liquid Propane Sales / Installation of Sound/Communication Equipment
Junk Yard / Other (Describe):
Conditions of Premises
Conditions of Premises: / Good Fair Poor Other (Describe):
Describe any special hazards:
Building Construction: / Brick Frame Other (Describe):
Age of Building: / Number of Stories: / Operations Area:
Number of Fire Extinguishers in building: / Date Last Inspected:
Years Insured in Business: / Years at This Location:
Business Hours: / Days Per Week:
Prior Losses (3 years): / Prior Carriers (3 years):
Yes / No / N/A
Shop Floors Clean and Dry?
Approved Absorbent Provided for Grease Spills?
Waste Oil Removed by a Licensed/Certified Waste Oil Removal Company?
UL Listed Safety Cans provided for Oil Soaked Cleaning Rags?
Shop Housekeeping Good?
Warning Signs Advising Customers Not Permitted In Work Area Conspicuously Posted?
Old Tires and Batteries Disposed of Properly?
Sale of Used Tires?
Sale of Re-treaded Tires?
Is there an Ice and Snow removal procedure?
Parking Bumpers?
Parking Area & Sidewalk Level? / Yes No / Parking Lot Marked? / Yes No
Free Standing Building? / Yes No Describe other tenant:
Sole Occupant of Building? / Yes No Describe other occupant:
Does Insured Perform: / Welding? / Yes No / Describe Booth:
Spray Painting? / Yes No / Describe Booth:
Describe Storage of Flammables: / I
Describe Disposal of Hazardous Wastes:
If the facility has guard dogs, are they restrained? / Yes No / Breed of Dog:
Shop Equipment: (check all that apply)
Hoist/Lifts / Paint Mixing Machine
Grease Pits / Compressor:
Part Cleaning/Degreasing Machines / Wheel Alignment
Oxy/Acetylene/MIG Welding Cutting Units / Grinding Machine
Spray Booth, Underwriting Lab Approved? / Tire Changing Machines
Spray Booth Sprinkler System / Engine Testing Equipment
Daily Spray Booth Cleaning / Fire Rated Storage Cabinets
No Smoking Sign Posted / Frame Straightening Machine
Condition of Equipment: Good Fair Poor (Describe)
If insured has Lift Devices, how many are there?
Is there a service contract? Yes No If Yes, date of last service:
Age of Lift: Hydraulic Driven Chain Driven Who is Owner of Lift?
COMPLETE DEALER SECTION IF POLICY PREFIX IS GD OR THE NON-DEALER SECTION IF POLICY PREFIX IS GN OR CG.
DEALER
Does Insured Sell: New Cars Used Cars Both
Number of officers, active partners, or other employees whose duties involve covered autos, or are furnished an auto:
Number of all other employees who work more than 20 hours per week:
Number of all other employees who work less than 20 hours per week:
Number of non-employees (independent contractors) using covered autos:
Number of non-employees (independent contractors) working for insured:
Number of Dealer Plates: / Number Transporter Plates:
Provide Plate Numbers: / 1. / 2. / 3.
4. / 5. / 6.
LIST ALL ACTIVE OFFICERS, EMPLOYEES & NON-EMPLOYEES (If more space required, continue in the Comments section on Page 4)
Name / Driver’s License Number / State / Position / Full Time / Part Time
Does Insured Operate a Towing Service? / Yes No(If Yes, Complete Below)
How many tow trucks does insured own or operate?
How many employees operate tow trucks?
Radius of operation: / 50 miles 100 miles Other:
For whom do they tow?
Insured By: (Carrier) / Policy Effective Date:

DC White Vendors Safety Evaluation (09-07)Page 1 of 4

NON-DEALER
Number of officers or partners active in business:
Number of employees earning over $100 per week:
Number of employees earning less than $100 per week:
Number of non-employees (independent contractors) working for insured
COMPLETE THE FOLLOWING IF INSURED OPERATES A GAS STATION WITH OR WITHOUT CONVENIENCE STORE
Number of Pumps: / Number of Bays:
If Insured has a Convenience Store Operation, Annual Food and Beverage Gross Sales:
Yes / No / N/A
Gas Pumps Provided with Barriers?
Gas Pumps Provided with Fire Suppression System?
Fire Extinguishers Provided as Gas Pumps?
Annual Gas Sales?
GARAGE PHYSICAL DAMAGE SECTION
COMPLETE THE FOLLOWING IF GKLL OR DEALERS PHYSICAL DAMAGE COVERAGE IS PROVIDED.
Type: / Valet / Restaurant/Club / Valet – Lot/Garage / Self Park – Lot / Self Park - Garage
Keys kept while open: / In Car / Pegboard / Office / Other
Keys kept after close: / In Car / Pegboard / Office / Other
Ticketing System: / Memory / Split Ticket / N/A / Other
(attach copy of Ticket, if applicable)
If this is a service station, are customer vehicles left on premises overnight? / Yes No
Facility Protection: / None Post & Chain Fence Guard Dog Alarm
(check all that applies) / CCTV / Describe in detail:
If the facility has an alarm, is it: Local Central Station
Car Capacity Inside: / Car Capacity Outside:
Stored or Parked on Premises: / Vehicles Held For Sale / Customer Vehicles
Maximum value of any 1 car stored or parked on premises: / $ / $
Average value of any 1 car stored or parked on premises: / $ / $
Average value of all cars stored or parked on premises: / $ / $
Maximum value of all cars stored or parked on premises – inside: / $ / $
Maximum value of all cars stored or parked on premises – outside / $ / $
Flammable Liquids and Materials: / Yes / No / N/A
Are underground gasoline storage tanks properly vented?
Proper and Secure storage of Propane Tanks?
Proper Management, Maintenance and Testing of underground gasoline storage tanks?

Comments:

DC White Vendors Safety Evaluation (09-07)Page 1 of 4

/ SAFETY SURVEY PHOTO FORM
Insured Name:
Insured #:
Link #:
Date of Visit:
Vendor:

Note: Please insert picture then put the text below the picture:

Safety Survey Photo FormPage 1 of 106/07/2006