8-H. Bonfire Contractor Safety Assessment Form.pdf
PDF 73 KB Posted
- Attached to
- Leak Detection Services State and local contract opportunity
- Solicitation number
- FY26-RFP-20
- 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 compliance of potential contractors. The form requires detailed information about an organization's safety program, including documentation of a written safety and health program, employee safety training, OSHA annual summaries, and OSHA citations for the past three years. Contractors must also provide their North American Industrial Classification System (NAICS) code and their company's and industry's DART (Days Away, Restricted, or Transferred) incidence rates.
The form mandates submission of various insurance certificates, including workers' compensation, commercial general liability, automobile liability, and professional liability insurance (if applicable). The insurance documentation requirements are dependent on the specific scope of the project or contract. Contractors with 10 or fewer employees are exempt from certain documentation requirements. The form must be signed and dated by an authorized representative, and all requested documentation should be provided to demonstrate the contractor's commitment to safety and regulatory compliance.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 1-F. Bonfire References Form.pdf | ||
| 3-A. Bonfire Procurement Portal Instructions.pdf | ||
| 4-B. FY26-RFP-20 Leak Detection Services RFP.pdf | ||
| 7-G. Bonfire MWSBE Utilization Form.pdf | ||
| 2-D. Bonfire Proposal Submission Form.pdf | ||
| 5-C. FY26-RFP-20 Sample Contract.docx | DOCX document | |
| 6-E. Pricing Worksheet.docx | DOCX document |
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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 .