Step 1 of 4 25% Contractor's Firm NameStreet AddressCityStateZip CodeContact NameTelephone NumberAre you a WBE or MBE company?*YesNoIf yes, please provide your Certificate #Has your company been federally or state debarred?*YesNoFor which Irex U.S. Subsidiary are you submitting this form?- SELECT COMPANY -Advanced Energy ProtectionAdvanced Industrial ServicesAdvanced NuclearAdvanced Specialty ContractingArgus ContractingAtlantic Contracting & SpecialtiesCornerstone Services GroupIrex CorporationI-Star Energy SolutionsSummit ContractingVertical Access SolutionsName of person at this Irex subsidiary company who asked you to complete this form: Please provide the following information relative to your firm's safety performance and program:Certificate of Liability Insurance AND Experience Modification Rate (EMR) Please obtain from your insurance agent a Certificate of Liability Insurance showing the general liability, auto (if applicable) and workers compensation coverages. The certificate must list the above selected company's name as a certificate holder as well as an additional insured. Please attach the certificate to this form.Insurance Requirements: General Liability: $2,000,000 Automobile Liability: $1,000,000 Umbrella/Excess: $5,000,000 each occurrence Workers Compensation: $1,000,000Does your company meet the insurance requirements stated including limits and excess limits, waiver of subrogation, and additional insured status?YesNoSample Certificate of Insurance:Click Here For SamplePlease obtain from your insurance agent (or state fund, if applicable) your interstate EMRs for the last three rating periods. If you do not have an interstate rating, obtain your intrastate EMRs. Then complete the following data:Current policy year - Effective DatesCurrent policy year - Modification RateOne year previous - Effective DatesOne year previous - Modification RateTwo years previous - Effective DatesTwo years previous - Modification RateIs your firm self-insured for Workers’ Compensation claims?YesNoWe require backup for the above information. Please furnish a letter from your insurance agent, insurance carrier, or state fund (on their letterhead) verifying the EMR data listed above.How many years has your firm been in business under your present firm name? OSHA Recordable IncidentsFurnish a copy of your firm’s OSHA Forms 300 and 300A from the past three (3) years. It is unlikely we can qualify your company to bid work without these forms.Some firms are not required to complete the OSHA 300 Log because they have too few employees (less than ten at any time during the calendar year) or are exempted by virtue of the services they perform. If you don’t complete an OSHA 300 Log, is it because your firm:Has too few employees?YesNoPerforms a service, which is exempted from completing an OSHA 300 Log?YesNoIf you do not complete an OSHA 300 Log and you answered “No” to the above questions, please explain.The answers you provide in this section may determine whether you will be permitted to bid work. You are responsible and accountable for providing accurate information. Using your past three years OSHA Logs, provide the following injury and illness information. Provide the information whether or not you are required to keep a Log per OSHA recordkeeping guidelines:Enter details for Year 1Year*Number of Fatalities*Number of lost workday cases*Total number of restricted cases*Total number of recordable cases*Total employee hours worked*Number of employees*Enter details for Year 2Year*Number of Fatalities*Number of lost workday cases*Total number of restricted cases*Total number of recordable cases*Total employee hours worked*Number of employees*Enter details for Year 3Year*Number of Fatalities*Number of lost workday cases*Total Number of restricted cases*Total number of recordable cases*Total employee hours worked*Number of employees*Have you had any regulatory agency inspections in the last three (3) years?YesNoIf you answered “Yes”, please provide copies of the documentation, including any citations issued. Attach the following documents: 2MB MAXIMUM TOTAL FILE SIZE ACCEPTEDFile 1: EMR VerificationFile 2: OSHA LogsFile 3: Certificate of InsuranceFile 4: W-9 FormFile 5: WBE or MBE Certificate (if applicable)File 6: Other (if applicable) Safety ProgramDo you hold safety meetings for: Field Supervisors?YesNoFrequencyDailyWeeklyMonthlyQuarterlySemiannuallyAnnuallyTitle of person conducting meeting and datesDo you hold safety meetings for: Employees?YesNoFrequencyDailyWeeklyMonthlyQuarterlySemiannuallyAnnuallyTitle of person conducting meeting and datesNew hires? OrientationYesNoFrequencyDailyWeeklyMonthyQuarterlySemiannuallyAnnuallyTitle of person conducting meeting and datesSubcontractors?YesNoFrequencyDailyWeeklyMonthlyQuarterlySemiannuallyAnnuallyTitle of person conducting meeting and datesDo you conduct job safety inspections?YesNoFrequencyDailyWeeklyMonthlyQuarterlySemiannuallyAnnuallyTitle of person conducting meeting and datesPlease list all safety training that your company provides to its employees, e.g. Fall protection, Scaffolding (include any specialty training).Does your company use Job Safety Analysis?YesNoDoes your company use occupational clinics for injured employees?YesNoDoes your company have a drug and alcohol testing program?YesNoDo you have a formal (written) safety program available upon request?YesNoYour NameYour TitleYour EmailIrex Risk Management will email notification to you upon approval. You must receive approval prior to work. Irex Corporation Risk Management Dept PO Box 1268 Lancaster, PA 17608 USA Donna Ridinger: dridinger@irexcorp.com NameThis field is for validation purposes and should be left unchanged.