Become a Subcontractor

Safety Pre-Qualification

Please fill out the form in its entirety. If you feel an item is not applicable, please indicate 鈥淣/A鈥� and explain why in the provided comment box. Any information omitted without explanation or falsified, subcontractor may be deemed Not Qualified.

Workers Compsensation Carrier*

Policy Expiration Date*

EMR, OSHA RECORDABLE AND LOST TIME INFORMATION

Provide your firm's Experience Modification Rate (EMR) for the three most recent years.

EMR Current Year*

EMR Prior Year

EMR Year Before Last

Provide the following information from your OSHA 300 Log(s). If you are exempt from maintaining OSHA 300 Logs (10 or fewer employees), please state that in the comment box below and provide the number of injuries requiring medical attention (beyond first aid) in the previous 12 months:

Current Year

Prior Year

Year Before Last

Number of Fatalities

Number Fatalities Current Year*

Number Fatalities Prior Year

Number Fatalities Year Before Last

Total Recordable Incident Rate

Recordable Incident Rate Current Year*

Recordable Incident Rate Prior Year

Recordable Incident Rate Year Before Last

Days Away Restricted Transfer Rate

Days Away Restricted Txfr Rate Current Year*

Days Away Restricted Txfr Rate Prior Year

Days Away Restricted Txfr Rate Year Before Last

Total Recordable Cases

Recordable Cases Current Year*

Recordable Cases Prior Year

Recordable Cases Year Before Last

Total Cases with Days Away, Restrictions, Transfers

Days Away Restrictions Transfers Current Year*

Days Away Restrictions Transfers Prior Year

Days Away Restrictions Transfers Year Before Last

Number of Labor Hours Worked

Labor Hours Current Year*

Labor Hours Prior Year

Labor Hours Year Before Last

Explanation of injuries for companies with 10 or fewer employees*

Citation History

Have you had any OSHA, EPA, safety, environmental or regulatory agency citations in the last 3 years?*

Citation History Comments*

Comments

This field is for validation purposes and should be left unchanged.

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