1

As part of the EHS Plan, the Contractor’s Procurement Plan must comprehend the following

when considering potential subcontractors and identify the process by which these

requirements will be executed. This information is required by all subcontractors. An officer of the company must certify by signing below, that all the information is current and accurate.

Contractors and all lower-tier contractors bidding and performing work on Samsung construction projects are required to enroll in the Contractor Safety Assessment Program HIGHWIRE. To enroll go to https://www.highwire.com

1. Contractor Information 

Fax:

E-mail:

2. Worker Compensation 

Contractor Pre-Qualification – I-CO 

Policy Expiration Date:

Phone:

Person Completing Form:

Type of work performed:

Insurance Carrier:

E-mail:

Fax:

Phone:

Company Address:

Company Name:

List your firm’s experience modification rates (EMR) for the three most recent years.

Three years ago

Two years ago

One year ago

Attach copies of supporting documentation from your worker’s compensation insurance

carrier.

3. OSHA Recordable and Lost Time Information 

A. Number of injuries and illnesses: (Last 3 years)

3 yrs. 2 yrs.

1 yr.

1. Number of lost days

2. Number of restricted days

3. Number of OSHA recordable injuries

4. Number of fatalities.

5. Number of lost time accidents

Attach copies of OSHA Logs for the last three years.

B. Actual Corporate / nationwide total employee hours work for the past three years.

Three years ago

Two years ago

One year ago

C. Have you received any local, state, federal or International safety citation in the past three years?

If yes please explain:

Yes

No

4. Safety Policy – (A Copy of your company safety manual that covers the topics below)

Do you have an orientation program for new hires? Yes

No

_

_

If yes, does it include instruction on the following? Yes or No

A. Head Protection

B. Eye Protection

C. Hand Protection

D. Hearing Protection

E. Respiratory Protection

F. Fall Protection

G. Scaffolding

H.	Perimeter Guarding
I.	Housekeeping

J. Fire Protection

K.	First Aid Practices and Equipment
L.	Emergency Procedures

M. Hazard Communication

N. Lockout/Tagout Control of Hazardous Energy

O. Electrical Safety

P. Rigging and Crane Safety

Q. Safe Lifting/Back Safety

R. Competent Person Requirements

Do you have a Safety Training program for newly hired or newly promoted foremen?

Yes

No

If yes, does it include instruction on the following? Yes or No

A. Safe Work Practices

B. Supervisors Responsibility

C.	Conducting Toolbox Safety Meetings
D.	Emergency Procedures
E.	Injury Reporting Procedures
F.	Accident Investigation Techniques
G.	Fire Protection and Prevention
H.	Supervisor’s Role in Orientation

Do you hold "Toolbox" Safety Meetings"?

Yes

No

If yes, how often?

Weekly

Bi-Weekly

Monthly

5. OSHA Training 
A minimum of OSHA 10 is required, and supervisors must have an OSHA 30

6. Drug Policy
May be subject to random / post-incident drug testing. Submit a copy of your Drug Screening Policy.

, subcontractor to Daifuku, has read the attached Intel

documents and will follow all Intel safety policies.

Print Name

Signature

Title

Date

 Please forward a copy of your copy of your company safety manual / site safety plan, proof of Highwire membership along with this form to LPalella@daifukuamerica.com, GRobinson@daifukuamerica.com, and Kgriffin@daifukuamerica.com