Worksheet for Commercial Automobile

By Ramon Pierce,2014-08-10 06:55
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Worksheet for Commercial Automobile

    Texas Department of Insurance

    Property & Casualty Program Loss Control Regulation, Mail Code 103-9A ;333 Guadalupe P. O. Box 149104, Austin, Texas 78714-9104 ;;512-322-3435 telephone 512-305-7425 fax


    Commercial Automobile Liability Insurance


    PART A

     1. a. Policy #: b. Policyholder Name:

     c. Policy Eff. Date: d. Location Address:

     e. # of Texas Locations: f. Est. Annual Premium: g. Insurance Company: 2. a. Radius of Operation: b. # of Drivers: c. Number & Type of Vehicles:

     Current Policy Yr: 1st Prior Yr: 2nd Prior Yr: 3. Number of Occurrences/Claims: / / / 4. Frequency Indicator: 5. Loss Ratio: 6. Number of Visits: 7. Date of Last Loss Control Visit: 8. Worksheet Completed by: Date:

    PART B

    1. Description of operations (similar to that shown in industry guides; i.e. type cargo carried, number of miles driven per year, etc.): 2. List the potential risks/hazards associated with the operations of this policyholder that have or could cause a loss or claim. 3. Describe the types of losses experienced by this account, as reflected in Part A above, and any trends identified. 4. Describe the loss control measures taken by your company to control identified loss sources.

    5. Training assistance and/or informational materials provided:

    ; Have you provided training assistance to the insured?

     If so, in what form?

    If not, for what reason (other than an insured not requesting assistance)?

PC386 Rev. 06/11 Page 1 of 2


PC386 Rev. 06/11 Page 2 of 2

    Part B (Cont'd)

    ; Have you provided loss control informational materials to the insured?

     If so, list the type of materials (i.e., mail-outs, pamphlets, etc.)

    6. Does the insured have a formal (written) safety program?

    ; If so, what is your opinion of it? Provide examples of different aspects of the program (or lack thereof) that caused you to

    reach this conclusion:

    ; How was this information validated/confirmed (other than through application information submitted)?

    7. Does the insured have a fleet maintenance program?

    ; If not, what provisions have been made for the maintenance of vehicles?

    ; What recommendations/assistance have you provided for the development or improvement of such a program?

    8. Loss/accident investigation and analysis provided?

    ; Describe the type of analysis conducted, its result/conclusions and the manner in which the results were presented to the


    9. Current status of this policyholder account:

     Non-Renewed by company (explain circumstances) Cancelled by company (explain circumstances)

     Non-Renewed by policyholder (explain circumstances) Current in-force policy

    Instructions for Completing Part A 1. a. Policy Number. b. Name of policyholder, e.g. "Acme Widget Company" c. Date current policy took effect. d. City in which policyholder's main office is located. e. Number of Texas locations f. Estimated annual premium for current policy year. g. The insurance company writing coverage.

    2. a. The estimated range of operation for the vehicles insured. b. Number of drivers. c. Number and Type of Vehicles insured on the policy.

    stnd3. Number of occurrences/claims in the current policy year, 1 prior policy year, and 2 prior policy year.

    4. Frequency Indicator = Number of Occurrences X 100 Number of Vehicles

    5. Loss Ratio = Incurred Losses_ (expressed as a percentage)

     Earned Premium

    stnd6. Number of visits to the account made by the Loss Control Representative in the current policy year, 1 prior policy year, and 2 prior policy year.

    7. Date of last loss control visit to, or direct communication with, the insured by a Loss Control Representative.

    8. Name of person who has completed this worksheet followed by the date the worksheet was completed.


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