Annual Subcontractor Recertification

Section 1: General Information

Business Name(Required)

As written on W-9.

CEO/Majority Owner First Name(Required)

First Name Last Name

Federal Tax ID or Social Security Number(Required)

Headquarters Address(Required)

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

Number of Full Time Employees(Required)

Business Contact Name(Required)

First Name Last Name

Business Contact Phone(Required)

Business Contact Email(Required)

Section 2: Insurance & Bonding

Insurance Broker / Producer Name(Required)

Insurance Broker / Producer Address(Required)

Street Address Address Line 2 City State ZIP Code

Broker Contact Name(Required)

First Last

Broker Contact Phone(Required)

Broker Contact Email(Required)

Section 4: Safety Performance

Please provide data for the previous completed calendar year. All document uploads are required annually.

Calendar Year Reported(Required)

What is the Experience Modification Rate (EMR)?(Required)

How many DOT Violations?(Required)

How many OSHA Violations?(Required)

How many Environmental Violations?(Required)

How many Recordable Incidents?(Required)

How many Total Hours Worked?(Required)

What is your Total Recordable Incident Rate (TRIR)?(Required)

Upload: OSHA Form 300 Log (required annually)(Required)

NOTE: If you employ 10 or fewer employees and are exempt from keeping OSHA Form 300 logs, please attach a blank document

Drop files here or

Max. file size: 2 GB.

Upload: EMR Letter (required annually)(Required)

Drop files here or

Max. file size: 2 GB.

Has your Safety Lead changed in the past year? *(Required)

Yes

No

If Yes — provide new Safety Lead Name, Title, Email, and Phone:

Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Upload: Safety Program/Manual(Required)

Danella requires all active subcontractors to submit a current copy of their company safety program or manual on an annual basis. Please upload your most recent version below, including the effective or revision date. If your safety program has not changed since your last submission, please resubmit the current version.

Drop files here or

Max. file size: 2 GB.

Section 6: Certifications

Has your company obtained any new certifications in the past year not previously submitted to Danella?(Required)

Yes

No

(e.g., MBE, WBE, DBE, OSHA 30, state contractor licenses, specialty trade certifications)

If Yes, please describe:(Required)

Upload: New Certification Documentation(Required)

Drop files here or

Max. file size: 2 GB.

Have any previously submitted certifications expired or been revoked?(Required)

Yes

No

If Yes, please describe:(Required)

Section 7: Work Performed with Danella

Please report on work performed specifically on Danella projects during the past 12 months.

Total hours worked on Danella projects:

Total number of Danella projects completed:

Were there any incidents, safety violations, or corrective actions issued on Danella projects?(Required)

Yes

No

If Yes, please describe:(Required)

Are there any outstanding contract disputes or unresolved issues with Danella?(Required)

Yes

No

If Yes, please describe:(Required)

Section 8: Subcontractor Self-Assessment

How would you rate your company's overall performance on Danella projects in the past year?

Excellent

Good

Fair

Poor

What is one area where your company improved in the past year?(Required)

What challenges, if any, do you anticipate in the coming year that may affect your work with Danella?(Required)

Is there anything Danella can do to better support your company or improve the working relationship?(Required)

Section 9: Authorized Signature

By filling out this section, I certify that the information provided in this Annual Recertification Form is true, accurate, and complete to the best of my knowledge. I understand that any material misrepresentation may result in the termination of my company’s relationship with Danella.

Authorized Representative(Required)

First Name Last Name

Authorized Representative Title(Required)

Authorized Representative Email(Required)

Authorized Representative Phone(Required)

CAPTCHA

Annual Subcontractor Recertification

Section 1: General Information

Section 2: Insurance & Bonding

Section 3: Legal & Compliance

Section 4: Safety Performance

Section 5: Workforce & Operations

Section 6: Certifications

Section 7: Work Performed with Danella

Section 8: Subcontractor Self-Assessment

Section 9: Authorized Signature

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