Subcontractor Health And Safety Prequalification Form Page 6
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6Subcontractor Health and Safety Prequalification Form
List your current and last policy year workers’ compensation insurance loss-ratio:
Current Year:
Last Year:
NOTE: Loss Ratio is calculated as “Incurred Losses”, times 100, divided by your WC Premium
OSHA Injuries/Illnesses
List your OSHA 300 safety information for the past three years (from OSHA 300 Log):
Last Year:
Second Year:
Third Year:
Lost Workday Cases (Column H)
Recordable Injuries (Sum, Column G, H, I, & J)
Restricted Injuries (Column I)
Medical Cases (Column J)
Fatalities (Column G)
Hours Worked (From OSHA 300A)
Signature
Title:
Signature:
Date:
Page 6 of 6
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