LOSS CONTROL SERVICES FORM

<%@ Language=Inherit from Web site %> FEE Based Insurance Inspections and Account Loss Control File Management

Text Box: FIELD UNDERWRITING INSPECTION AND
INSURED COMMERCIAL LOSS CONTROL ACCT MGMT SERVICES Phone: 484 239 4436

PROPERTY & CASUALTY FIELD UNDERWRITING & ACCOUNT LOSS CONTROL SERVICES

Global Loss Control offers a specialized and professional services in account loss control, field underwriting, and risk assessment for commercial insurance P & C underwriters, loss control manager's, and commercial businesses, please check required services included within this form.

GLOBAL LOSS CONTROL CUSTOMER ACCOUNT INFORMATION SECTION INSURANCE COMPANY NAME CUSTOMER PURCHASE ORDER/CONTRACT NUMBER DATE OF THIS REQUEST DATE REQUEST REQUIRED INSURED OR PROSPECT PERSONAL AND CONFIDENTIAL DATA SECTION

DATE SUBMITTED POLICY NO.

POLICY EFFECTIVE DATE

IS THIS A REQUIRED QUOTATION? YES NO

NAME - POLICY HOLDER

OWNER NAME

CITY STATE

ZIP

CONTACT PERSON

BUSINESS PHONE NO.

TYPE OF BUSINESS

PREMIUM SIZE (CHECK BOX BELOW)

$10 k TO $50 k $50K TO $250K $250K TO $500K $500K and $1 million +

Other

ANNUAL PAYROLL$

PROPERTY VALUE $

CONTENTS VALUE $

ANNUAL GROSS RECEIPTS

INSURED ACCOUNT LOSS CONTROL AND FIELD UNDERWRITING SERVICE REQUEST SECTION

LIST SPECIAL ATTENTION ITEMS IN SPACE PROVIDED BELOW

All rights reserved. Information in this document (Website) is subject to change without notice does not represent a commitment on the part of Global Loss Control, Inc. No part of this document or (Website) shall be reproduced or transmitted in any means, electronic or mechanical, including photocopying and recording, for any purpose without the express written permission of Copyright© Global Loss Control, Inc, - P. O. Box 3085, Easton, Palmer, PA 18043. BY D J B Last Update January 2012 COPYRIGHT© GLOBAL LOSS CONTROL® DJB Jr., F.A.C.F.E., A.S.A. LICENSE 85 - ACCREDITED SAFETY AUDITOR

I. PROPERTY	VII. ACCT. LOSS CONTROL MGT SERVICES
`Fire and E.C.`	`Safety Program Auditing`
`DIC Perils, Flood Quake`	`Fire protection analysis`
`All Risk`	`Plan review`
`Business Interruption`	`Special hazards identification`
II. LIABILITY	`Process safety program audit`
`Comprehensive General`	`Training needs assessment`
`X C U`	`Safety training`
`Products./ Completed Operations`	`Job Tasks Analysis & Observation`
`Mfg. & Contractor Liability`	`Personal Protective Equipment (PPE) review`
`Garage Liability`	`Accident incident investigation`
III. Worker's Comp.	`Large loss claim review`
`Industrial`	Fleet Loss Control Program Services
`Construction`
`Mercantile`
`Service industries`	`Industrial Hygiene plan review and program audit`
`Environmental spill response workers`	`Contracts job site evaluation and quality of workmanship`
`Environmental spill contractors`	`Restaurant assessment package` UL 300 system review Hood and Duct service plan review Purveyors listing and assessment Sanitation review
`Environmental remediation contractors`	`Specialty Contractors assessment package`
IV. CRIME
`Money in and out`
`Safe Burglary`
`Open Stock`
`Storekeepers`

`Fleet`
`Business Owners Policy (BOP)`
`Special Quoting Request`