Special Inspections + Materials Testing

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[Select your state] *

LITIGATION / CONTRACT DISPUTES

List any judments, arbitrations, liens, insurance claims, or lawsuits the firm has been subject to within the past 5 years. If there are none, respond by saying there were none.

Please enter all judgements, arbitrations, liens, insurance claims, and/or lawsuit descriptions: *

Has firm at any time failed to complete a contract or had a contract terminated? *

Yes

No

If yes, please explain: *

File Upload

Maximum file size: 5MB

CRIMINAL BACKGROUND INFORMATION

Has the firm, any affiliate, or any of the current or former principal owners, stockholders, or officers or managerial employees:

been convicted of a misdemeanor and/or found in violation of any administrative, statutory, or regulatory provisions in the past five (5) years? *

Yes

No

been convicted of a felony, and/or crime related to truthfulness and/or business conduct in the past ten (10) years? *

Yes

No

have any felony, misdemeanor and/or administrative charges currently pending? *

Yes

No

If you answered "Yes" to any of the above questions, please provide an explanation:

Insurance Coverage

State your standard coverage limits in COLUMN 2 below.

POLICY

Occurrence (or claim) limit

Aggregate limit

GCL

GCL Occurrence Limit

GCL Aggregate Limit

Auto

Auto Occurrence Limit

Auto Aggregate Limit

Umbrella / Excess

Umbrella / Excess Occurrence Limit

Umbrella / Excess Aggregate Limit

Pollution / Liability

Pollution Liability Occurrence Limit

Pollution Liability Aggregate Limit

Workers Compensation

Workers Compensation Occurrence Limit

Workers Compensation Aggregate Limit

Professional Liability

Professional Liability Occurrence Limit

Professional Liability Aggregate Limit

Cyber / Network Security Liability

Cyber / Network Liability Occurrence Limit

Cyber / Network Liability Aggregate Limit

If a contract requires additional insurance limits, would you be willing to consider purchasing additional insurance coverage? *

Yes

No

Health & Safety

Do you have a written Health & Safety Program? *

Yes

No

If Yes, please attach a copy. *

Maximum file size: 33.55MB

Do you provide site-specific Health & Safety Plans? *

Yes

No

Who is responsible for executing the site specific plans?

Does your site-specific health and safety plans include Job Hazard Analysis (JHA)? *

Yes

No

If Yes, provide an example for similar services to be provided.

Whats is the number of safety professionals on-staff within your firm? *

Does your Health & Safety Program call for field safety inspections?

Yes

No

If Yes, who conducts them and how often?

If Yes, do you document findings of inspections and provide written reports on outcomes?

Yes

No

Do you have an Accident Investigation & Reporting Program? *

Yes

No

Do you have a drug and alcohol screening program? *

Yes

No

Do you currently conduct pre-employment drug and alcohol screening? *

Yes

No

If No, are you willing to conduct drug and alcohol screening if so directed by a contract?

Yes

No

Are employees provided with health and safety training? *

Yes

No

Health & Safety (Cont.)

If Yes, does the training include:

Company Health and Training Policy

Yes

No

Company Health and Safety Rules and Safe Work Practices

Yes

No

Driving Safety

Yes

No

Electrical Safety

Yes

No

Fall Protection

Yes

No

Hazard Recognition and Reporting

Yes

No

Injury Reporting

Yes

No

Personal Protective Equipment

Yes

No

Fire Prevention

Yes

No

Housekeeping

Yes

No

Emergency Response and Rescue

Yes

No

First Aid

Yes

No

Safety Meeting Attendance

Yes

No

Radio Frequency Energy Safety Training Program

Yes

No

Competent Tower Climber and Rescue Training

Yes

No

Confined Space Training

Yes

No

Energy Isolation and Lockout / Tagout

Yes

No

Hazard Communication Training

Yes

No

Motorized Equipment Operator Training

Yes

No

Excavation and Trenching

Yes

No

Health & Safety (Cont.)

How many of your employees had OSHA 10-Hour training in the past 3 years?

How many of your employees had OSHA 30-Hour training in the past 3 years?

Does the work your employees perform require the use of fall-arrest equipment? *

Yes

No

Do you retain the services of an outside safety consultant? *

Yes

No

Do you conduct safety meetings? *

Yes

No

If Yes, how often? (e.g. daily, weekly, monthly) Explain.

Do you conduct Toolbox Talks? *

Yes

No

If Yes, how often? (e.g. daily, weekly, monthly) Explain.

Do you employ full-time competent tower climbers and rescue personnel? *

Yes

No

If Yes, how often? (e.g. daily, weekly, monthly) Explain.

Health & Safety (Cont.)

Provide the following information for the last 3 years. You must respond to all questions even if your firm is not required to maintain OSHA logs.

YEAR (most recent 3 years)

Current Year

Prior Year

Worker's Compensation
Experience Modification Rate (EMR)

Worker's Compensation Experience Modification Rate (EMR) (Current Year) *

Worker's Compensation Experience Modification Rate (EMR) (Prior Year)

Number of Fatalities
(list any, explain in Supplemental Information field at the end of this form.)

Number of Fatalities (Current Year)

Number of Fatalities (Prior Year)

Lost Work Day Incident Rate
(total lost-time recordable cases x 200,000 / total hours worked.)

Lost Work Day Incident Rate (Current Year) *

Lost Work Day Incident Rate (Prior Year) *

OSHA Recordable Incident Rate
(total OSHA recordable cases x 200,000 / total hours worked)

OSHA Recordable Incident Rate (Current Year)

OSHA Recordable Incident Rate (Prior Year)

Total Number of Hours Worked
(per occurrence)

Total Number of Hours Worked (Current Year)

Total Number of Hours Worked (Prior Year)

The following upload fields allow for uploading of multiple files.

To upload multiple files please click-and-hold the CTRL key and left-click with your mouse.
Once you have selected the file(s) hit the "Open" button on the the dialog box.

Attach copies of your OSHA 300 & 300A logs for the last 3 years (Not required).

Maximum file size: 10MB

If you are human, leave this field blank.

LITIGATION / CONTRACT DISPUTES

CRIMINAL BACKGROUND INFORMATION

Insurance Coverage

Health & Safety

Health & Safety (Cont.)

Health & Safety (Cont.)

Health & Safety (Cont.)

The following upload fields allow for uploading of multiple files.

Special Inspection Feedback Form

Section

Section

Section

Service Evaluation

Section

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