JOIN BOZVILLE CONSTRUCTION TEAM. Open Form Prequalify GENERAL INFORMATION Company Name * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Fax No Tax Id CONTACT INFORMATION Name * First Name Last Name Email * CONTACT Owner Accounting Estimating Safety SPECIFIC INFORMATION Union Members YES NO Check all that apply Minority Owned Woman Owned Veteran Owned Small Business CSI CODE Work Areas Work Performed SAFETY INFORMATION NAICS Workers Comp EMR provide letter from Carrier verifying your Company's EMR This section must be completed using the OSHA 300 form (last three years). #OSHA Recordables 2021 2020 2019 Recordable Rate 2021 2020 2019 Lost Workday Case Rate 2021 202 2019 DART Work Rate DART 2020 2019 Fatalities 2021 2020 2019 OSHA Citations 2021 2020 2019 Total Manhours Worked 2021 2020 2019 Average # of Employees 2021 2020 2019 Does your Company maintain/implement the following: Written Safety Policy YES NO Drug Free Workplace Policy YES NO Conduct Safety Inspections YES NO Investigate Incidences, Injuries and near misses YES NO Occupational Healthcare Provider YES NO Full Time Safety Director YES NO SUBMISSION By entering your name below, I hereby certify the above information is accurate, correct and true. Submitted By * Thank you for submitting your prequalification forms. we would reach out to you should we need additional information. If you have questions or comments, reach out to Bozville Construction via email at info@bozvillehomeservices.com
