Sample Subcontractor Safety Questionnaire
Company: __________________________________________ Date: _____________________
I. Your Firm's Safety Performance and Program
A. Workers Compensation Insurance - Experience Modification Rate (EMR)
1. Please obtain from your insurance agent (or state fund, if applicable) your interstate
EMR for the last three rating periods and complete the following.
Policy Year Modification Rate
Most Recent Policy Year
1 year previously
2 years previously
Are the above rates interstate or intrastate? ___________________
If intrastate, which state? ________________
If your EMR is exactly 1.0 for any policy year, is it because your firm is (was) too new or
too small to have an EMR calculated?
[ ] Yes [ ] No
Is your firm self-insured for Workers Compensation claims?
[ ] Yes [ ] No
2. We require back-up for the above information. Which of the following methods
would be acceptable:
Furnish a letter from your insurance agent, insurance carrier, or state fund (on
their letterhead) verifying the EMR data listed above, or
Furnish a photostat of the last 3 years, Experience Rating Calculation Sheets,
which your insurance carrier should forward to you annually; or
Furnish a photostat of the page of your last 3 year's insurance policies that shows
the modification rate and the coverage period; or
If you're in a state fund state, such as Ohio or West Virginia, furnish a photostat
of the state's last 3 years' annual statement page that shows the modification rate
and the coverage period:
B. OSHA Recordable Incidents
Furnish a copy of your firm's OSHA 200 Log and total man-hours for each year
from the last 3 years. Indicate which injuries occurred at the GOCO facility.