PNCG Contractor Safety Questionnaire

Company Name: ___________________________________________________________ Address: _________________________________________________________________
How many years has your organization been in business under your present firm name?
Parent Company Names: City: State: Zip:
Describe Principal Services Performed:
Who will be the Safety Contact for your firm? (Name, Position)_______________________________,____________________________________
Insurance Coverage Requirements Unless otherwise agree to in writing, the Contractor shall, at its sole expense, maintain in effect at all times during the performance of work, insurance coverage’s with limits, which may be a combination of primary and excess, not less than those set forth below with insurers and policy forms satisfactory to Your Company Here or its subsidiaries. Contractor shall cause its lower-tier contractors at the jobsite to obtain and maintain insurance policies to protect Your Company Here in accordance with the same requirements. All insurance provided by Contractor and its lower-tier contractors shall be primary and any similar insurance maintained by Your Company Here shall be excess thereof and not contributing with Contractor’s or its lower-tier contractors’ insurance. Your Company Here shall be given thirty (30) days written notice in the event of cancellation, non-renewal or material alteration of any policy. Commercial General Liability - Your Company Here its subsidiaries and Employees shall be made Additional Insured on the Commercial Liability Policy(ies). Employer’s Liability Limit shall be no less than: $1,000,000 General Aggregate $1,000,000 Product/Completed Operations aggregate $1,000,000 Personal and advertising Injury $1,000,000 Each Occurrence $50,000 Fire Damage $5,000 Medical Expense Initial here to indicate compliance with above:_____________________ Automotive Liability – Your Company Here, its Subsidiaries, and Employees shall be made Additional Insured on the Automotive Liability policy(ies). Employer’s Liability limit shall be no less than identified below: $1,000,000 Initial here to indicate compliance with above: _______________________ Workers’ Compensation and Employer’s Liability – A waiver of subrogation in favor of Your Company Here shall be obtained from Workers’ Compensation and Employer’s Liability insurer. Employer’s Liability limit shall be no less than that identified below: $500,000 Each Accident $500,000 Disease (Policy Limit) $500,000 Disease (Each Employee) Initial here to indicate compliance with above: _______________________ Excess Liability – Your Company Here, its Subsidiaries, and Employees shall be made Additional Insured on the Excess Liability policy(ies). Employer’s liability limit shall be no less than that identified below: $400,000 Each Occurrence Initial here to indicate compliance with above: _______________________ Explain non-compliance below: _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
7. Workers Compensation Experience Modification Rate (EMR) Data: If you do not have an EMR rating please explain why. EMR for the past three (3) years: Last Year __________ 2 Years Ago_________ 3 Years Ago_________ State of Origin: __________________ EMR Anniversary Date: ___________
Please provide your Injury/Illness rates for the past 3 years:
Year	# of Work-Related Recordable Injuries/Illnesses	# of Days Away from Work, Restricted Work and Job Transfer Cases	Total # of Employees (Average # for each year)	Total Case Incident Rate (TCIR)	Days Away from Work, Restricted Work and Job Transfer Rate (DART)



NOTE 1: Calculations to determine injury/illness rates can be completed with the above info. If you wish to do the rate calculations, use the following equation for calculating injury and illness rates: Number of Recordable Cases or DART Cases X 200,000/ Total work hours for that year = TCIR or DART Rate NOTE 2: Data should be applicable to the total corporation. NOTE 3: If your company is not required to maintain an OSHA 200/300 log, please provide information from your worker’s compensation insurance carrier itemizing all claims for the last three (3) years
Principal NAICS (North American Industry Classification System) code _____________ Have you received any regulatory (EPA, OSHA, etc) or criminal citations in the last three (3) years? Yes No If yes, please explain: __________________________________________________________________
11. SAFETY AND HEALTH PROGRAMS It is an expectation that Contractors and their Sub-Contractors comply with all applicable Governmental Regulations. This includes having written programs and providing safety training to its employees. As a minimum, Contractors must be trained in: Hazard Communication Lockout Electrical Safety Personal Protective Equipment Proof of training may be required for the following if applicable to Services or the Project: Confined Space Entry Hot Work NFPA 70E PPE Respiratory Protection By signing below, the Contractor agrees to provide the appropriate training for its employees and takes full responsibility for completing training in compliance with applicable OSHA regulations. The Contractor will provide proof of training when requested by an Your Company Here Representative. Name (Print)________________________ Name (Sign)____________________________ Date:_______________
Incident Investigations: In the event of an Contractor injury, first aid, near miss or property damage, the Contractor agrees to investigate the incident and participate/cooperate with Your Company Here to determine the root cause(s). The contractor will make available to Your Company Here all facts, findings and documents. Initial if accepted: ___________ Drug and Alcohol Testing: The Contractor will provide drug and alcohol testing for any employee involved in a serious injury, near miss or property damage incident. The Contractor will also provide such tests if there is reason to suspect an employee is under the influence of a drug or alcohol. Initial if accepted: ___________
Performance – Experience has shown that written programs and training do not necessarily ensure that a Contractor and its employees work safely and follow applicable regulations. Future work at the plant will be based upon project after project performance. Violations of Health and Safety rules and regulations, as well, as serious or repeated injuries, near miss incidents and property damage will result in removal from our qualified contractor list. Initial if accepted: ___________ Orientation – Your Company Here will require each Contractor employee to undergo a Health and Safety Orientation prior to the start of any job. The orientation will include a test. Therefore, Your Company Here requires that all employees posses the ability to understand english. Initial if accepted: ___________ Daily Safety Meeting – At the start of everyday the Contractor Supervisor will hold a safety huddle. The safety huddle will be documented and available for review at the job site. Initial if accepted: ___________ Inspections – Your Company Here reserves the right to inspect the job site at any time. Deficiencies are to be corrected immediately. If at-risk-behaviors are discovered, the contractor employee could be asked to leave the job site and not return. At the same time, the Contractor shall inspect the project site and take immediate action for any findings. Initial if accepted: ___________
Contractor Qualification Questionnaire completed by:____________________________________________ Date:__________________Telephone: ___________________________ Fax:__________________________ Please send this questionnaire to the Your Company Here EHS Department - Attention: EHS Leader.

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This Section is to be completed by the Your Company Here Health and Safety Representative

11. SAFETY AND HEALTH PROGRAMS

It is an expectation that Contractors and their Sub-Contractors comply with all applicable Governmental Regulations. This includes having written programs and providing safety training to its employees. As a minimum, Contractors must be trained in: