Sample Subcontractor Safety Questionnaire

Exhibit 2.6.2

DOE-HDBK-1101-96

Sample Subcontractor Safety Questionnaire

Company: __________________________________________

Date: _____________________

I. Your Firm's Safety Performance and Program

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

Modification

Year

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 years' 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:

OSHA Recordable Incidents

1. Furnish a copy of your firm's OSHA 200 Log and total manhours for each year from

the last 3 years. Indicate which injuries occurred at the GOCO facility.

2. Some firms are not required to complete OSHA 200 Log, because they have too few

employees.