3-I. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- On-Call Plumbing Services State and local contract opportunity
- Solicitation number
- FY26-RFP-08
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
The document is a Contractor Safety Assessment Form issued by Charlotte Water, designed to evaluate potential contractors' safety programs and documentation. The form requires comprehensive safety and insurance information from contractors, including details about their written safety program, employee training, OSHA records, incident rates, and various insurance certificates. Contractors must provide their company information, NAICS code, DART incidence rates for both their company and industry, and submit copies of workers' compensation, general liability, automobile liability, and professional liability insurance certificates.
The form is structured to ensure contractors meet safety standards and have appropriate insurance coverage before engaging in work with Charlotte Water. It includes provisions for smaller companies with 10 or fewer employees, who may be exempt from certain documentation requirements. The assessment aims to verify contractors' safety preparedness by requesting three years of historical safety data, including OSHA summaries, citations, and injury rates. Contractors must complete the form, providing all requested information and obtaining authorization from a company representative before submission.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 5-B. FY26-RFP-08 On-Call Plumbing Services RFP.pdf | ||
| 2-D. Bonfire Proposal Submission Form.pdf | ||
| 6-C. FY26-RFP-08 Sample Contract.pdf | ||
| 8-G. Bonfire MWSBE Utilization Form.pdf | ||
| 9-H. Employee’s Licensing and Certifications.pdf | ||
| 1-F. Bonfire References Form.pdf | ||
| 4-A. Bonfire Procurement Portal Instructions.pdf | ||
| 7-E. Pricing Worksheet for FY26-RFP-08.pdf |
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Text version
Contractor Safety Assessment Form
1. Organization Information:
Company Name:
On-Site Representative: Phone #:
Email:
Safety Representative: Phone #:
Email:
2. Safety Program Documentation:
Yes N/A Does your company have a written safety and health program that is available upon request?* Are your employees current on all applicable safety-related training?
Provide copies of your OSHA annual summary (Form 300A) for the past 3 years.^ Provide copies of any OSHA citations or violations for the past 3 years.
Provide your company’s NAICS** code.
Year Rate What is your company’s DART incidence rate for the past 3 years?
What is your industry’s DART incidence rate for the past 3 years?
* A written safety program is not required for companies with 10 or less employees.
^If your company is/was exempt from filing Form 300A for any given year, provide an explanation detailing such exemption (e.g., less than 10 employees).
** NAICS – North American Industrial Classification System – If you need assistance with this information, please refer to the Bureau of Labor Statistics (BLS) website at www.bls.gov or contact a safety consultant.
3. Insurance-Coverage Documentation:
Yes N/A A copy of your workers’ compensation certificate of insurance A copy of your commercial general liability certificate of Insurance A copy of your automobile liability certificate of insurance A copy of your professional liability certificate of insurance for errors and omissions (if applicable)
Based on the scope of the project/contract, insurance documentation must be submitted.
4. Sign and date the form:
Authorized Signature: Date:
Print Name:
File details come from the government source that posted it. Updated .