5-I. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- Charlotte Water Tree Removal Services
- Solicitation number
- FY26-RFP-15
- Issued by
- Mecklenburg County, Charlotte City, North Carolina
About this file
This is a Contractor Safety Assessment Form for the City of Charlotte, North Carolina's Tree Removal Services contract opportunity. The form requires contractors to provide comprehensive documentation of their safety credentials and insurance coverage before being considered for this work, which involves tree and vegetation removal services for Charlotte Water in connection with water and sanitary sewer construction projects, after-hours and holiday/weekend emergency services, and disaster emergency response within the Charlotte area.
The form mandates submission of organizational information including company name, on-site representative details, and safety representative contact information. Contractors must demonstrate a written safety and health program, current employee safety training, and provide OSHA Form 300A annual summaries for the past three years (or documentation of exemption for companies with ten or fewer employees). Additionally, contractors must disclose any OSHA citations or violations from the past three years, their NAICS code, and their company's DART incidence rate for the past three years compared to the industry standard. Insurance documentation requirements include certificates of workers' compensation, commercial general liability, automobile liability, and professional liability for errors and omissions where applicable based on the project scope.
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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 .