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Ofc Form 26 - Work Certificate For Contractors Before Beginning Their Work On Public Projects - New Hampshire Department Of Transportation Page 2

3. Provide proof of compliance with NH Department of Labor safety program requirements under

RSA 281-A:64, in the following form:

a. By signing and submitting this form, you agree to provide employees with safe

employment; to furnish personal protective equipment, safety appliances and safeguards; to ensure

that such equipment, appliances and safeguards are used regularly; and to adopt work methods and

procedures which will protect the life, health and safety of employees.

b. Do you have 15 or more employees? YES or NO (Please Circle One)

If yes, you agree to administer a joint loss management committee composed of the following named

persons:

Employer representative(s):

Employee representative(s):

c. Do you have 15 or more employees? YES or NO (Please Circle One)

If yes, you are required to prepare a written safety program and file a Safety Summary Form with the

Commissioner of Labor; attach to this form the Safety Summary Form prepared under Department of

Labor regulations Lab 515.16 and Lab 602.02. (This requirement applies to all employers, including

non-resident employers. The Safety Summary Form can be downloaded from the NH Department of

Labor website forms link at )

By signing and submitting this form, you are providing a sworn statement that workers’

compensation coverage shall remain in effect, covering each person controlled or directed by

you to work on the project, for the duration of his or her anticipated work on the project. Any

person who fails to comply or who falsifies information is subject to a civil penalty of up to

$2,500 plus $100 per person per day of noncompliance and shall not be allowed to bid or work

on state projects for up to 5 years.

Signed and submitted on this date: _______________________, 20__

By this contractor, subcontractor or independent contractor:

Business Name: ________________________________________________________

Address: ______________________________________________________________

Telephone number: ____________________Fax number:________________________

Owner or Authorized Executive signature: ___________________________________

Printed name and job title: ________________________________________________

This Form and all supporting documentation shall be returned to the Prime Contractor, who shall

forward it with each subcontractor approval submission to: NH DOT

OFC Form 26 (Rev: January 4, 2016)

Ofc Form 26 - Work Certificate For Contractors Before Beginning Their Work On Public Projects - New Hampshire Department Of Transportation Page 2