Company Name:

*

Federal Tax ID (TIN for Canada):

*

Mailing Address:

*

Country:

State:

*

City:

*

Zip:

*

Phone:

( ) - *

Fax:

( ) - *

Web Site:

North American Industry Classification Code (NAICS): *

Which states do you do business? *

Type of Work:

*

3.1 Identify person directly responsible for the Health & Safety Program at your company.

Name:

*

Title

*

Phone:

() - *

Fax:

( ) -

Email:

*

3.2 Workers Compensation Experience Modification Rates (EMR): Provide below information:

State/Interstate:

*

Do not have an EMR.

EMR for the last three years:

2023 /

*

2022 /

*

2021 /

*

3.3 Summary of Incidents / Injuries: Provide the following data regarding illnesses and injuries.(If maintained, information can be taken from OSHA 300 Forms.)

Are OSHA 300 and 300 A logs of work-related injuries and illnesses maintained for company. Yes No

Number of Incidents / Injuries that resulted in:(Column on OSHA Log)		2023	2022	2021	Current YTD
1	Death (Column G)
2	Days Away from Work (Column H)
3	Job Transfer / Restriction (Column I)
4	Treatment Exceeded First Aid (Column J)
	Total Incidents (Column G + H + I + J)
	Total Employee Hours Worked

3.4 Do you have a written Health and Safety Program.

Yes No

3.5 Do you conduct formal Health and Safety inspections?

Yes No

Are the inspections documented?

Yes No

Are the deficiencies and corrections documented?

Yes No

3.6 Do your employees have documented training in the following:

Hazard Communication	Yes No	Specify:
Respitory Protection	Yes No	Specify:
PPE	Yes No	Specify:
Hearing Conservation	Yes No	Specify:
HAZWOPER	Yes No	Specify:
Confined Space Entry	Yes No	Specify:
Fall Protection	Yes No	Specify:
Scaffolding	Yes No	Specify:
Excavations	Yes No	Specify:

3.7 Have you received any regulatory (EPA, OSHA, etc.) civil or criminal citations in the last three years? Yes No

3.8 Do you hold site Health & Safety meetings for employees? Yes No

If "Yes", are the meetings held:	Specify:
Are the meetings documented?	Yes No

3.9 Do your employees have a substance abuse program?

Yes No

If "Yes", indicate whether it includes the following:

Pre-employment Testing	Yes No
Random Testing	Yes No
Testing for Cause	Yes No
Post-Accident Testing	Yes No
DOT Testing	Yes No

Document	Year
OSHA 300 Logs	2023
	2022
	2021
OSHA 300A Summary	2023
	2022
	2021
EMR from Insurance Carrier	2023
	2022
	2021
Copies of any regulatory (EPA, OSHA, etc.) or civil citations that occured in the last three years or a summary describing the incident(s) and how it was resolved.

Name:

*

Phone:

() - *

I certify, to the best of my knowledge, the information provided above is accurate and correct.