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Subcontractor Prequalification Form
pulice-admin
2021-01-28T23:17:12+00:00
Company Name + Address
Company Representative Name
Phone
Email Address
Website
General
Has company performed work for any of Pulice Construction projects in the past year? If so, provide Pulice project name and location.
Provide NAICS Code
What services will company be providing?
If any, what portions of the work will your company be subcontracting?
Service State(s) for your Company
Minority & Disadvantage Affiliation? (Provide Certification/Affiliation Information)
Required Submittals
(all applicable submittals MUST be provided and labeled accordingly)
Last three (3) calendar years + current year health, safety, or environmental related citations, violations, or other applicable regulatory agency notices and associated corrective actions.
Last three (3) calendar years + current year injury or incident data/logs that applicable regulatory agency(ies) require Company to maintain (I.E., OSHA300 Logs)
Provide Last three (3) calendar years + current year (EMR) Experience Modification Rate. (Must be from insurance broker or workers' compensation carrier.)
Current Company health, safety, and environmental program.
Provide all training records applicable to scope of work & regulatory requirements.
HSE Program
Do you have a documented pre-employment or new hire safety & health orientation program?
YES
NO
Does your company hold mass meetings for employees + supervision?
YES
NO
If so, how often?
DAILY
WEEKLY
MONTHLY
Do you conduct jobsite safety inspections?
YES
NO
If so, how often?
DAILY
WEEKLY
MONTHLY
Is Pre-Task Planning Risk Assessment conducted prior to the start of each shift? (I.E., JSAs, Job Briefings, etc.)
YES
NO
Will you have fulltime supervision on site?
YES
NO
Do you employ a fulltime safety professional dedicated to HSE?
YES
NO
What is the name + title of your company's HSE Professional?
What is the email address of your company's HSE Professional?
What is the phone number of your company's HSE Professional?
HSE Performance History
All fields must be populated with a numerical value. If no data is available, indicate with a 0
Current EMR Insurance Rate
EMR Rate for the following years
Current Employee Count
Employee Count for the following years
Current Total Hours Worked
Total Hours for the following years
Current Work Related Incidents/Illnesses
Current Work Related Incidents/Illnesses for the following years
Current Job Transfers
Current job transfers for the following years
Current Total Work Restrictions
Current work restrictions for the following years
Current work restrictions for the following years
Current Total of lost times
Current total Lost Times for the following years
Current Total of Fatalities
Current Total of Fatalities for the following years
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