LOS S CO N T RO L AL ER T

Contractor Selection Worksheet

This worksheet is designed to aid in the evaluation of a contractor’s qualifications to complete work on your behalf. It allows you
to focus on a contractor’s past safety performance, insurance claim history and quality assurance practices. While this review is
no guarantee of future performance, it can be an indicator of a contractor’s unsuitability for a particular project or of problems
that need to be corrected before a contractor commences work. Completing this worksheet is not a complete review of a contrac-
tor’s suitability for a particular project. You are encouraged to complete a more in-depth review using additional information from
a variety of sources. Everest National Insurance Company and Everest Indemnity Insurance Company assume no liability for the
use of this worksheet or information developed during your contractor selection review.

Project: __________________________ Completed by: __________________ Date: _________

Firm Name:
Contact/Phone/e-mail:

Scope of Work to be Completed:

Project Start –End Date:

Experience/References:

License Number/Exp:

Subs of this Firm:

Insurance Coverage

Required Actual Eff Date Exp Date Carrier Rating

Limits
Limits
Liability:

Workers’ Comp:

Auto:

Property/Inland Marine:

Comments

Safety Program Review

Written Program:
Review of inspection and train-
ing records:
Responsible Person(s):

Changes Needed:
Jobs Requiring Competent Per-
sons:
Names of Competent Persons
for each job:

Contractor Selection Worksheet July 2011

 Page 2
EVEREST LOSS CONTROL ALERT

Safety Record Review

WC Experience Mod:

OSHA Citations:

Any Serious, Repeat or Willful Citations?

Prior Loss History-WC :

Prior Loss History-GL:

Prior Loss History-Other :

Steps Taken to Prevent Such Losses:

Construction Quality
Prior Construction Defect Claims:

QA Program:

Quality Assurance Coordinator:

Contract Review
Hold Harmless Agreement

Indemnification Agreements:

Waiver of Subrogation:

Additional Insured Status:

Vendor Accepted by: Date:

Loss Control is a daily responsibility of your individual management. This publication is not a substitute for your
own loss control program. The information that is provided in this Alert should not be considered as all encompass-
ing, or suitable for all situations, conditions, or environments. Each organization is responsible for implementing
their safety/injury/illness prevention program and should consult with legal, medical, technical, or other advisors as
to the suitability of using the information contained in this Alert.

CONTACT US
Westgate Corporate Center
477 Martinsville Road
P.O. Box 830
Westgate Corporate Center
Liberty Corner, NJ 07938-0830
477 Martinsville Road
P.O. Box 830
Liberty Corner, NJ 07938-0830

Loss Control Department

Everest focuses on specialty property and casualty insurance Phone: 908-604-3000
Phone: 908-604-3000
business and is licensed to conduct business in all 50 states, Fax: 908-604-3526
Fax: 908-604-3526
including the District of Columbia. Everest is rated A+ XV E-mail: losscontrol@everestre.com
E-mail: losscontrol@everestre.com
(Superior) by A.M. Best. To learn more about Everest, visit
our website at : www.everestnational.com
 EVEREST LOSS CONTROL ALERT

Instructions
1. Enter the complete name and any DBA’s of the contractor to be reviewed.

2. Provide the name and contact information for the individual at the contractor who has primary responsibility for overseeing
this contract and project.

3. Provide an overview of the scope of work to be completed by this contractor.

4. Provide estimated project start and end dates for this contractor’s work. See job schedule or milestones report.

5. Provide a brief review of the contractor’s overall experience, work history with your company and list at least 2 references that
have provided positive feedback on their qualifications.

6. Provide the contractors license number and verify that the license is current and complies with the scope of work. Search
State Contractors’ License Board to verify license.

7. List any and all subcontractors this contractor intends to use. Note: all lower tier subs must be approved by you and meet the
same insurance and contract requirements as the contractor. This questionnaire should be satisfactorily completed on all
lower tier subcontractors before they are allowed to work on the project.

8. Provide current insurance information on each line of coverage listed. The limits can be found on the policy Declaration Page
along with the effective dates and expiration dates. The carrier rating can be obtained free of charge from the A.M. Best web
site at http://www3.ambest.com/ratings/ . Only carriers with a rating of “A” or better should be allowed. Your contract with
the owner or builder may require a size rating for the carrier which is expressed as a numerical value. See your contract for
details.

9. Obtain a copy of the written safety program for the contractor and have it reviewed by your safety representative. This will
ensure that the contractor has a current program that applies to their operations and that it is active.

10. Contact the person responsible for the program and ask them to discuss what it contains and how it will apply to your work
site. This will also help verify that the program is active.

11. List any areas of non-compliance with your safety program or requirements. These must be corrected before the contractor
begins work.

12. List any planned work that will require a “competent person or qualified person” to be on site while it is completed. This would
include trenching and excavation, structural steel erection, scaffolding erection or use, use of fall protection, work with asbestos,
etc.

13. List the names and titles of the contractor’s competent persons who will be on the site at all times while such work is completed.

14. Obtain copies of any training certificates or training completion cards that indicate the individual is trained in the subject area in
question. In order to qualify as a competent or qualified person, the individual must have knowledge of the hazards involved in
the work, safety measures that need to be taken, and the authority to immediately correct potential hazards.

15. Obtain a copy of the contractor’s Workers’ Compensation Experience Modification Factor. This is often referred to as an X-
Mod, EMR or Experience Rating. It is available from the Policy Declaration Page or the Workers’ Compensation Insurance Rat

Contractor Selection Sheet With Instructions July 2011

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19. Prior Losses – Other may refer to Environmental (spill or pollution), Builders Risk claims or losses resulting from EPA,
Air Quality Management District or Regional Water Quality Control Board actions.

20. Comment on past loss history for construction defect claims. This is often a good predictor of future claims. Are
there any trends or large losses? What have they done about them?

21. Review contractor’s Quality Assurance Program. How are they ensuring quality construction on their projects?

22. List the name of the Quality Assurance Coordinator or individual responsible for implementing the QA program.

23. Contractor is willing to sign a contract with a hold harmless, indemnify and defend clause in your favor along with a
waiver of subrogation against you. These items will ensure their insurance pays the claims on a primary basis. You
should also be listed as an additional insured on their Liability Policy.

Loss Control is a daily responsibility of your individual management. This publication is not a substitute for your own loss
control program. The information that is provided in this Alert should not be considered as all encompassing, or suitable
for all situations, conditions, or environments. Each organization is responsible for implementing their safety/injury/
illness prevention program and should consult with legal, medical, technical, or other advisors as to the suitability of using
using
the information contained in this Alert. The information contained Loss Control is a daily responsibility of your individual
management. This publication is not a substitute for your own loss control program. The information that is provided in
this Alert should not be considered as all encompassing, or suitable for all situations, conditions, or environments. Each
organization is responsible for implementing their safety/injury/illness prevention program and should consult with legal,
medical, technical, or other advisors as to the suitability of using the information contained in this Alert. The information
contained in this publication is intended for general informational purposes only and is not intended to constitute legal
advice or opinions. You should contact an attorney if you need legal advice and/or you have any questions concerning
your obligations under any law, statute and/or code identified in this publication.

CONTACT US
Westgate Corporate Center
477 Martinsville
Westgate RoadCenter
Corporate
P.O. Box 830
477 Martinsville Road
Liberty Corner, NJ 07938-0830
P.O. Box 830
Liberty Corner, NJ 07938-0830

Loss Control Department

Everest focuses on specialty property and casualty insurance
Phone: 908-604-3000
Phone: 908-604-3000
business and is licensed to conduct business in all 50 states, Fax: 908-604-3526
Fax: 908-604-3526
including the District of Columbia. Everest is rated A+ XV (Superior) E-mail: losscontrol@everestre.com
E-mail: losscontrol@everestre.com
by A.M. Best. To learn more about Everest, visit

our website at : www.everestnational.com

Contractor Selection Sheet With Instructions July 2011