Email E-mail  Phone: 610-253-7252     Fax: 610-258-6114     
             "WE CONTROL LOSS THROUGH LOSS CONTROL ENGINEERING & MANAGEMENT"

PROPERTY & CASUALTY INSURANCE INDUSTRY

FEE BASED

LOSS CONTROL ACCOUNT MANAGEMENT

&

 FIELD UNDERWRITING INSPECTION SERVICES

REQUEST FORM

Global Loss Control offers a specialized and professional service in risk assessment for commercial insurance P & C underwriters and commercial business, which include physical protection evaluations, safety program auditing, workers compensation exposure review, CGL, multi peril, products liability surveys, environmental impact, etc. Please use the form below to request field underwriting inspection or account loss control management services.    

 

GLOBAL LOSS CONTROL CUSTOMER ACCOUNT INFORMATION SECTION

 

INSURANCE COMPANY NAME 

CUSTOMER PURCHASE ORDER/CONTRACT NUMBER   

DATE OF THIS REQUEST                  DATE REQUEST REQUIRED   

*UNDERWRITING OR L.C. SPECIAL ATTENTION RISK ITEMS ARE TO BE SUBMITTED IN THE SPACE PROVIDED BELOW 

 

INSURED OR PROSPECT

PERSONAL AND CONFIDENTIAL DATA SECTION

 

DATE SUBMITTED         POLICY NO.  

                                                                         EXPIRATION DATE   

 

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

 

ANNUAL PAYROLL       $    PROPERTY VALUE $  

                                                                                  CONTENTS VALUE     $  

 

ANNUAL GROSS RECEIPTS

LOSS CONTROL ACCOUNT MANAGEMENT

AND FIELD UNDERWRITING INSPECTION

SERVICE REQUEST SECTION

 

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 Other use remarks section below
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  
   
   
 

 

 

 

 

      

 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) August be reproduced or transmitted in any means, electronic or mechanical, including  photocopying and recording, for any purpose without the express written permission of  Global Loss Control, Inc, P. O. Box 3040, Easton, (Palmer) PA 18043 

 

 BY D J B www.Globallosscontrol.com 

Last Update January2009 

 

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