4-G. Bonfire Contractor Safety Assessment Form.pdf
PDF 87 KB Posted
- Attached to
- Pressure Washing and Exterior Cleaning Services
- Solicitation number
- FY26-RFP-16
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form used by Charlotte Water in North Carolina to evaluate the safety qualifications and compliance of contractors bidding on pressure washing and exterior cleaning services. The form requires contractors to provide comprehensive documentation across three main categories: organization information, safety program documentation, and insurance coverage. Contractors must submit evidence of written safety and health programs, current employee safety training, OSHA Form 300A summaries for the past three years, any OSHA citations or violations, their NAICS code, and their company's DART incidence rate compared to industry benchmarks. The form includes provisions for companies with ten or fewer employees that may be exempt from certain filing requirements, and contractors must provide explanations for any such exemptions.
The insurance documentation requirements mandate submission of workers' compensation certificates, commercial general liability certificates, automobile liability certificates, and professional liability certificates for errors and omissions where applicable based on project scope. The assessment form must be completed, signed, and dated by an authorized company representative and submitted with contact information for both an on-site representative and a dedicated safety representative. This safety assessment represents a pre-qualification requirement designed to ensure contractor compliance with occupational safety standards and adequate insurance protection for pressure washing operations at Charlotte Water facilities.
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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:
http://www.bls.gov/
| 1. Organization Information: |
| Company Name: |
| Phone #: |
| On-Site Representative: |
| Email: |
| Phone #: |
| Safety Representative: |
| Email: |
| 2. Safety Program Documentation: |
| N/A |
| Yes |
| 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. |
| Rate |
| Year |
| 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? |
| N/A |
| Yes |
| 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) |
File details come from the government source that posted it. Updated .