3-I. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- Storm Water Channel Cleaning Services
- Solicitation number
- FY26-RFP-09
- 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 the safety and insurance credentials of potential contractors. The form requires comprehensive documentation including a written safety and health program, current safety training records, OSHA annual summaries, OSHA citations, NAICS codes, and DART incidence rates for both the company and its industry over the past three years.
The form mandates submission of various insurance certificates, including workers' compensation, commercial general liability, automobile liability, and professional liability (if applicable). Contractors must provide these documents based on the specific project or contract scope. The form includes provisions for companies with 10 or fewer employees, who may be exempt from certain documentation requirements. A signature and date are required to validate the assessment, indicating the contractor's commitment to safety standards and compliance with Charlotte Water's contractual safety expectations.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .