TEP Vendor Annual EH&S Update |

TEP Vendor Annual EH&S Update

Business Name(Required)

First

Updated Billing Address?(Required)

YES

Address

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

Workers' Compensation Coverage

Updates Insurance Carrier?(Required)

YES

Name

First

Address

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

Phone

EMR Anniversary Date or WCB Account #

Provide History from Previous Year(Required)

YEAR

Experience Modification Rate

Canada Discount Rate (if applicable)

Total No. of Claims

Total Amount Paid in Claims

Please Upload EMR Verification Letter(Required)

Max. file size: 256 MB.

Safety & Health Performance

Does Your Company Employ more than 10 Workers?(Required)

YES

Provide History from Previous Year

YEAR

Average Number of Employees

Total Number of Work Hours

Number of Fatalities

Number of Lost Workday Cases

Number of Restricted/Transfer Cases

Number of Other Recordable Cases

Total Number of Cases

Has you company received citations/penalties associated with regulatory inspection (OSHA, EPA, WCB, etc.)?(Required)

YES

If YES - Provide Details

Please Upload Citation/Penalty Documentation

Drop files here or

Max. file size: 256 MB.

Please Upload OSHA 300 & 300A for Previous Year(Required)

Drop files here or

Max. file size: 256 MB.

Certificate of Insurance (COI)

Please Upload Current COI(Required)

Max. file size: 256 MB.

Certification (Contact Information for Person Completing this Form)

Name(Required)

First Last

Title(Required)

Date(Required)

Phone(Required)

Email(Required)

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Comments

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