{ Subcontractors : Berry Bros. General Contractors }

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Subcontractors

Complete the form below to register as a Berry Bros. subcontractor:

E-Mail Address:

Password:

Retype Password:

Company Name:

Address:

Address

City

State

Zip

Any Previous Company Name and Address:

Safety Contact:

Prepared By:

Phone Number:

Fax Number:

Check the types of work your company performs:

Painting / Abrasive Blasting

General Maintenance

Mechanic

Electrical

Welding

NDT

Construction

Roustabout Labor

Concrete / Foundation

Other (Describe)

Are you a Minority, Female, or Disabled Veteran owned Business?

Yes

No

Which one?

Contractor accepts and agrees to comply with all government and customer safety laws, rules and regulations:

Yes

No

Contractor understands Berry Bros.' accident notification policy:

Yes

No

Contractor management exhibits a commitment to continuing improvement of their safety and performance program:

Yes

No

Please provide / submit the following information for our files:

Number of Employees:

Total Number of Manhours worked for the last three years including current year:
2010:
2009:
2008:

Experience Modification Rate (EMR) for the last three years including current year:
2010:
2009:
2008:

Total Recordable Incident Rate (TRIR) for the last three years including current year:
2010:
2009:
2008:

Note: TRIR Formula

(Total No. Injuries & Illnesses X 200,000) / (Actual Manhours Worked)

NAICS / SIC Code:

Your insurance agent should know your code.

DOT Number if applicable:

1. Worker's Compensation Insurance Certificates:

Does your company carry Worker's Compensation Insurance?

Yes

No

If coverage is partial, list:

Deductible amount per incident: $

Total annual deductible: $

2. Safety Performance Information (Injury / Illness Experience):

Item	2010	2009	2008
Number of Fatalities?
Number of Lost Workday Cases?
Number of Days Lost from the Above Cases?
Non-Lost Workday Cases (Medical Treatment Only)?
Non-Lost Workday Case with Restricted Duty?
Total Number of OSHA Recordable Cases?

3. Management Safety Policy Statement:

Does your company have a written management safety policy that establishes responsibility and accountability for safety within your company?

Yes

No

4. Safety Procedures:

Does your company have written safety procedures specific to your type of work?

Yes

No

5. Emergency Response:

Does your company have a written emergency response plan for your employees while working on various client sites?

Yes

No

Are emergency contacts and numbers posted in a visible location on site?

Yes

No

6. Accident Reporting:

Does your company have written accident reporting / investigation procedures in place?

Yes

No

Who completes the accident investigation?

Are accident reports circulated for review with Management, Supervisors, field employees, clients?

Yes

No

7. New Employee Orientation:

Does your company provide safety orientation training for new hire employees?

Yes

No

If so, what topics are covered?

8. Safety Meetings:

Does your company conduct and document safety meetings?

Yes

No

If yes, who conducts the meetings and how often?

Are JSAs, JSEAs, JHAs, etc completed daily and before each new job task?

Yes

No

9. Jobsite Safety Inspections:

Does your company conduct documented safety inspections of jobsites and equipment?

Yes

No

If yes, by whom and how often?

10. Alcohol, Drug, and Contraband Control:

Does your company have an anti-alcohol/drug/contraband program?

Yes

No

If yes, does your drug and alcohol program include the following?

Pre-employment testing	Yes	No
Reasonable cause testing	Yes	No
Post-Accident testing	Yes	No
Random testing	Yes	No
Upon return to duty testing	Yes	No

11. Employee Safety Training:

Does your company provide safety training?

Yes

No

Do your training records identify...

The employee trained?	Yes	No
The date of the training?	Yes	No
The name of the instructor?	Yes	No
The means used to measure competency?	Yes	No

Are training records and training materials available for audit?

Yes

No

Complete the following summary of Safety Training provided to your employees as it applies:

Training Subjects	Provided	Frequency	Records Kept
First Aid / CPR / AED	Yes No N/A		Yes No
Bloodborne Pathogens	Yes No N/A		Yes No
Hazard Communication including MSDS	Yes No N/A		Yes No
Lockout / Tagout	Yes No N/A		Yes No
Electrical Safety	Yes No N/A		Yes No
Excavation Safety	Yes No N/A		Yes No
Confined Space Entry	Yes No N/A		Yes No
Personal Protective Equipment	Yes No N/A		Yes No
Hearing Conservation	Yes No N/A		Yes No
Respiratory Protection	Yes No N/A		Yes No
Fire Safety	Yes No N/A		Yes No
Fall Protection	Yes No N/A		Yes No
Crane Certification	Yes No N/A		Yes No
Forklift / Manlift Certification	Yes No N/A		Yes No
Injury Reporting	Yes No N/A		Yes No
Emergency Preparedness	Yes No N/A		Yes No
Housekeeping	Yes No N/A		Yes No
H2S Training	Yes No N/A		Yes No

Comments:

I agree with the above terms and regulations for Berry Bros. General Contractors

Federal Tax ID:

Contractor's License:

Rocky Mountain Division Civil/Mechanical

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