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?
 
Comments
Written Workplace Safety Program? (10 or more employees only): 
 
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?: 
 
If "YES", which organization(s)
Safety Committee Established? (25 or more employees only) 
 
If "YES", Please Describe:
Safety Representative?   
Percentage of time spent on safety:   %  
Safety Representatives Name:   
Contact Number:   
Completely Describe scope of various company operations:   

Do your employees work with or around any of the following?
  1. Elevations greater than: 15'?
     30'?
    Maximum height exposure
  2. Electrical Equipment voltages greater than 300 VOLTS AC?
  3. Hazardous Chemicals/X-Ray equipment
  4. Arenas/Stadiums/Halls?
  5. Days/Hours business open:
  6. Any group transportation of employees?
  7. Number and type of owned/leased vehicles?
  8. Radius of travel?  Any out of state travel? 
  9. Any delivery operations? 
    Any catering operations? 
  10. Are employees allowed personal use of corporate vehicles?
  11. Are MVR's checked at least annually on all drivers of corporate vehicles?
Completed by:   
Agency:   
Email Address:     
Phone Number:   
Fax: