WORKERS COMPENSATION INSURANCE

office:

801.432.8121

toll free:

866.642.8242

fax:

801.571.8165

Utah Business Insurance Company Inc
Safety Questionnaire

(Revised 3/12/10)

The following survey will be used to evaluate your company’s safety program for Utah Business Insurance Company, Inc. This information will be maintained in the strictest confidence possible and will not be released outside of Utah Business Insurance Company, Inc. the Plan Administrator.

Please complete this questionnaire thoroughly.

Company Name:
D.B.A:
Other related Entities/Units:
Average Number of Employees:	Full Time Part Time
Occupational Safety and Health (OSHA) citations in the past five years (final orders):	"Willful" citations or "Serious" citations? YesNo Comments
Written Workplace Safety Program? (10 or more employees only):	YesNo Note: A comprehensive written safety program is provided to all UBICPolicyholders at no cost.
Are you a current member in good standing of : Corporate Alliance, Utah Valley Homebuilders, Utah Masonry Council or Associated Builders & Contractors of Utah?:	YesNo If "YES", which organization(s)
Safety Committee Established? (25 or more employees only)	YesNo If "YES", Please Describe:
Safety Representative?	YesNo
Percentage of time spent on safety:	%
Safety Representatives Name:
Contact Number:
Completely Describe scope of various company operations:

Your employees work with or around any of the following
Scaffolding: Suspended? YesNo Conventional? YesNo Scaffold Erection? YesNo Elevations greater than: 15'? YesNo 30'? YesNo Maximum height exposure Leading Edge Work? YesNo If a roofer, do you roof above 5 stories? YesNo Excavation/Trenches Greater than 4’ deep? YesNo Greater than 18’ Deep? YesNo Tunneling? YesNo Maximum depth exposure Operating Heavy Machinery YesNo Cranes? YesNo Aircraft? YesNo Electrical Equipment voltages greater than 300 VOLTS AC? YesNo Sandblasting YesNo Painting? YesNo Paint Booths? YesNo Extremely Hazardous Chemicals? YesNo (Examples: strong acids, caustics, 2 part paints or epoxies, pesticides) Building Demolition? YesNo Asbestos Removal? YesNo Explosives/Fireworks? YesNo Vehicle Maintenance? YesNo Tire Mounting/Split Rims/Multi-Piece Rims? YesNo Gas Companies? YesNo Dealing/Distributing oil/gas lease operators/contractors? YesNo Activities over or under water? YesNo Vessels or dry-docks? YesNo Gas/Oil operations, drilling, rigging and derrick work, on/offshore, pipelines and wells? YesNo Railroad operations, repair or construction? YesNo Amusement Parks, Carnivals or Circuses? YesNo Arenas/stadiums/halls? YesNo Professional Sports Teams, sports events or grandstands? YesNo Methods used to transport employees to and from the work sites? What is the radius of operations? Types of Machinery / Equipment Operated?
Completed by:
Agency:
Email Address:
Phone Number:
Fax:
The above information is correct and complete to the best of my knowledge!