LARSEN AND TOUBRO LIMITED

BUILDINGS & FACTORIES INDEPENDENT COMPANY

Ref : SP 8.1.4 - 2
EHS Pre‐ Qualification Checklist - Tier 2
COMPANY NAME : ADDRESS FOR COMMUNICATION :

MAIN CONTACT NAME & DESIGNATION : TELEPHONE NUMBER : Mail ID:

TYPE OF COMPANY / INDUSTRY / FIRM (TICK AS APPROPRIATE)

Private : Partnershi Proprietary :
p:
Supplier Others
(Please specify) :

NATURE OF THIS CONTRACT :

COMPANY WORK HISTORY

What are your core Business activities ?
Have you worked with L&T? (If Yes, which Unit
& Project)

MAJOR JOBS EXECUTED

Customer & Location Type of Work Year Customer EHS Feedback/ Award

ACCIDENT/INCIDENT DETAILS
No.of Occupational Fatalities in last 5 years
No.of Major Injuries in last 5 Years
Please provide details of Accident/Incident Details
Detail of the Accident/Incident Type (Fatality, Major , Minor Injuries) Year

Please state the employment classification/designation, Qualification & Experience of employees to be engaged on this project and estimate
of numbers to be engaged for each classification.
Classification/Designation (Engineer, Supervisor, No.of Certification/Qualification Year of Experience
Safety Engineer, Safety supervisor, Rigger, Welder Employees
etc)

Please state the equipments to be deployed on this project and years of usage.
Equipment (Crane, Excavator, Grader, Major power tools, etc) Years of Usage

I/We declare that to the best of my knowledge the answers submitted in this Pre-Qualification Questionnaire are correct. I understand that
the information will be used in the evaluation process to assess my company’s suitability for LTHE’s requirements

Date                               

Name:

Designation:

Place:

Signature of authorized Person with company seal:

Sensitivity: LNT Construction Internal Use

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