Safety

Contact Information
- Policy Number:*
- Name of Company:*
- Contact Name:*
  First Last
- Email:*
- Office Phone:*
- Mobile Phone:*
- Title:*
Business Operations
Briefly Describe Operations:*
How many years in business?*
How many years total experience by Management?*
% of work that is:*
% Residential % Commercial % Industrial
(must total 100%)
% of work that is*
% New Construction % Remodel/Renovation/Repair
(must total 100%)
Is work performed outside of Louisiana?*
- Yes
- No
If yes, in what states is work performed?*
- How many out of state jobs/year?*
- Length of jobs (days, weeks, months, etc)?*
Do you, your business, or any workers own, operate, lease or charter aircrafts for business use?*
- Yes
- No
If yes, please describe for what purpose, how often, and who pilots the plane:*
- Number of owner/officers?*
- Number of full-time direct employees?*
- Number of employees under 18 years of age?*
- Number of part-time direct employees?*
- Number employed less than 6 months?*
Number of employees with total experience?*
0-1 year 1-5 years Over 5 years
- Are company vehicles provided to employees?*
  - Yes
  - No
- Motor vehicle records (MVR) checked for drivers?*
  - Yes
  - No
- How many company vehicles?*
- What is the max driving radius (miles)
Is employee group transportation provided?*
- Yes
- No
Indicate each workforce type that applies:
- Roofing
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Painting
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Electrical
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Plumbing
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Masonry/Stucco
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Flooring
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Other
- Other
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Framing
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Drywall
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- HVAC
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Landscape
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Job site clean up
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Supervision
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Interior Trim
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Concrete
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Cabinetry
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Insulation
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Site Prep / Dirt Work
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
- Office/Clerical
  - Direct Employees
  - Insured Subs
  - Uninsured subs
  - Uninsured Contract Labor / Casual (Day) Labor
Are Certificates of Insurance obtained and verified for Insured Subcontractors?*
- Yes
- No
- N/A
- If uninsured subcontractors are used, how many crews?
- How many workers in each crew?
- If uninsured contract/casual(day) laborers are used, how many?
- How often are they used?
- How/where do you obtain these laborers?
- What is the max # of direct employees and/or uninsured laborers that are on-site at a given time?*
Are any of the following tasks performed?
- Crane Operations?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Tunneling?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Confined Space entry?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Steel Erection?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Work over water?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Debris hauling/removal other than job site cleanup?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Demo other than renovation/remodeling/repair?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Excavation/Tenching (greater than 4 ft)?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Tree trimming and/or removal?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- Work performed over 45 ft or 3 stories in height?*
  - Yes
  - No
- Please explain and include which workforce type performs this task (Direct Employee, Insured Sub, Uninsured sub, Uninsured contract/casual (Day) Laborer)*
- If yes, what is the maximum height worked (feet)?*
- What type of work is performed above this height?*
Safety/Loss Control
- Does your company have a written safety program?*
  - Yes
  - No
- Please upload copy of your written safety program
  Max. file size: 10 MB.
- Are safety meetings conducted with workers?*
  - Yes
  - No
- Does your company have a written Drug and Alcohol Testing Policy?*
  - Yes
  - No
- If yes, have all direct employees and/or uninsured laborers read and signed the Policy?*
  - Yes
  - No
  - N/A
- Do all direct employees/uninsured laborers complete the Post-Hire Second Injury Board Knowledge Questionnaire once employment has been offered?*
  - Yes
  - No
  - N/A
- Is this questionnaire updated annually?*
  - Yes
  - No
  - N/A
- Are you aware that all accidents must be reported to the SIF Claims Department, as soon as possible, by calling 1-877-542-2743*
  - Yes
  - No
- Are job site safety inspections performed?*
  - Yes
  - No
- Are workers required to wear Personal Protective Equipment (PPE) when needed?*
  - Yes
  - No
Please check if you would like a Loss Control Consultant to contact you about any of the following FREE services:
- Safety meetings
- Jobsite visit to assist with hazard identification / jobsite inspection
- Assistance with your Safety/Loss Control Program (Review, development, and/or implementation)
- Other
Other*
A Loss Control Consultant will review your questionnaire and may contact you with additional questions. If there are no additional questions, you will receive a confirmation letter that may contain recommendations that will assist you with your Safety / Loss Control Program. Additional Safety/Loss Control resources can be found at www.SIFsafety.com.
- Member Signature*
- Date*
  MM slash DD slash YYYY

Contact Information

Business Operations

Indicate each workforce type that applies:

Are any of the following tasks performed?

Safety/Loss Control