\r\n \r\n Please Note: You can save your changes as you work on this\r\n form to return later.\r\n \r\n
\r\n\r\n Indicate how many employees you employee (appx)\r\n
\r\n\r\n \r\n Describe the nature of business your organization typically\r\n performs*\r\n \r\n
\r\n\r\n Are you a division of a corporation?\r\n
\r\n\r\n Parent Corporation Address:\r\n
\r\n\r\n Are you self-insured for Worker’s Compensation insurance?\r\n
\r\n\r\n Does your company use subcontractors?\r\n
\r\n\r\n Form completed by:\r\n
\r\n\r\n \r\n Do you have a dedicated fulltime health & safety professional\r\n within your company?*\r\n \r\n
\r\n\r\n \r\n Who is responsible for health & safety within your organization?\r\n \r\n
\r\n\r\n Does your SAFETY program address the following elements:\r\n
\r\n\r\n \r\n Does your written S&H Program contain the following\r\n programs/topics? Identify those topics that your work will fall\r\n under.\r\n \r\n
\r\n\r\n \r\n List your company’s Workers’ Compensation Experience Modification\r\n Rate (EMR) for the three (3) most recent years (enter N/A if you have none):\r\n \r\n
\r\n\r\n \r\n Use your OSHA 300 log (or equivalent) to record the number of\r\n injuries and illnesses for the last three (3) years:\r\n \r\n
\r\n\r\n {x.fileName} {' '}\r\n
\r\n \r\n The Contractor/Subcontractor agrees to abide by all CoreStates\r\n Health & Safety Requirements. Failure to adhere to CoreStates\r\n Health & Safety Requirements may result in suspension or removal\r\n from CoreStates job sites and/or termination of the Contract.\r\n \r\n
\r\n\r\n \r\n Please fill out all required fields (marked with a *) above\r\n \r\n
\r\n \r\n )}\r\n {!unsavedChanges && (\r\nA record for this subcontract exists.
\r\n\r\n Please contact a CoreStates representative for more\r\n information.\r\n
\r\nThank You
\r\n\r\n
\r\n The Certificate of Insurance must include the above coverage\r\n and must name{' '}\r\n Core States Construction Services, Inc. as an\r\n additional insured. The following information must be listed\r\n on the Certificate of Liability Insurance:{' '}\r\n \r\n {' '}\r\n \"Core States Construction Services, Inc. is named as\r\n additional insured on a primary and non-contributory basis\r\n under the above mentioned polices except the workers\r\n compensation. This includes ongoing & completed operations.\r\n A waiver of subrogation in their favor is included in all of\r\n the above-mentioned policies\"\r\n \r\n
\r\n\r\n The Certificate of Insurance must include the above coverage\r\n and must name Core States, Inc. as an\r\n additional insured. The following information must be listed\r\n on the Certificate of Liability Insurance:{' '}\r\n \r\n {' '}\r\n \"Core States, Inc. is named as additional insured on a\r\n primary and non-contributory basis under the above mentioned\r\n polices except the workers compensation. This includes\r\n ongoing & completed operations. A waiver of subrogation in\r\n their favor is included in all of the above-mentioned\r\n policies\"\r\n \r\n
\r\n\r\n \r\n Please Note: All fields below are required. You can\r\n save your changes as you work on this form to return later.\r\n \r\n
\r\n\r\n \r\n List your three largest contract values for the last twelve\r\n months:\r\n \r\n
\r\n\r\n \r\n The following figures refer to your financials at the end of your\r\n most recent fiscal year. Please indicate the month and year in\r\n which your fiscal year ended:\r\n \r\n
\r\n\r\n {x.fileName} \r\n
\r\n \r\n Please fill out all required fields (marked with a *) above\r\n \r\n
\r\n \r\n )}\r\n {!unsavedChanges && (\r\n