Vendor Onboarding Form (TEST) |

Step 1 of 9

CONTACTS

BILLING CONTACT

First Last

BILLING TITLE

BILLING PHONE

BILLING EMAIL

SALES CONTACT

First Last

SALES TITLE

SALES PHONE

SALES EMAIL

OPERATIONS CONTACT

First Last

OPERATIONS TITLE

OPERATIONS PHONE

OPERATIONS EMAIL

EMERGENCY CONTACT

*Contact should have ability to contact drivers and arrange for services outside of office hours.

NAME

First Last

CELL PHONE

SAFETY COMPLIANCE

1. What was your workers compensation Experience Modification Rate (EMR)? (Note - This can be located on insurance documentation for our company.

Current year

1st Previous Year

2nd Previous Year

If your rate is greater than 1.0, please reply with explanation.

2. What was your Lost Workday Case (LWC) Rate? (Note – This can be located on the OSHA 300 log. The calculation reflects the number of LWC divided by the total man-hours worked times 200,000.

Current year

1st Previous Year

2nd Previous Year

If your rate is greater than 1.0, please reply with explanation.

3. What is the LWC Rate for your industry?

(Note – This can be found on the OSHA web site http://www.osha.gov/oshstts under BLS Workplace Injury, Illness, and Fatality Statistics. Select “Incidence rates for nonfatal occupational injuries and illnesses by industry” for the most current year available. Use information in the “Injury/Illness LWC Total column).

4. What was your Total Recordable Case (TRC) Rate?

Current year

1st Previous Year

2nd Previous Year

(Note – This can be located on the OSHA 300 log. The calculation reflects the number of TRC divided by the total man-hours worked times 200,000.

If your rate is great than your industry rate, please reply with explanation.

Primary SIC CODE

List any job related State or Federal OHSA enforcements against your company in the last three (3) years:

Does your company complete background checks on all active employees at time of employment?

YES

Does your company complete drug screenings at the time of employment?

YES

Does your company complete drug screenings post accident?

YES

Does your company have a documented Sustainability Policy or Green Initiative?

YES

Please upload a copy of your Sustainability Policy or Green Initiative

Max. file size: 512 MB.

REFERENCES

Name 1

First Last

Company 1

Address 1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email 1

Phone 1

Name 2

First Last

Company 2

Address 2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email 2

Phone 2

Name 3

First Last

Company 3

Address 3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email 3

Phone 3

Vendor Onboarding Form