Sample Subcontractor Safety Questionnaire

DOE-HDBK-1101-2004

Exhibit 2.6.2

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.