SESC Members Intake Form

Member Plan ^*

Bronze (1-2 Staff)

Silver (3-10 Staff)

Gold (11-20 Staff)

Platinum (21-30 Staff)

Commercial (31-40 Staff)

Prime (Over 41 Staff)

Client ^*

Trade ^*

Business Name ^*

Business Registration # ^*

Business Address ^*

Phone # ^*

Email ^*

# WCB Accounts ^*

WCB Industry Code ^*

WCB Account # ^*

Name of principle company contract ^*

Principle Contract # ^*

Email ^*

Name of alternate company contract ^*

Who will authorize / sign the policies of the safety program?

Alternate Contract # ^*

Email ^*

Name ^*

Title ^*

# Employees (At Peak, Annually)

OFC. ^*

SHOP ^*

WHSE ^*

FIELD ^*

OTHR ^*

# Employees (Current)

OFC. ^*

SHOP ^*

WHSE ^*

FIELD ^*

OTHR ^*

Manager / Supervisors

OFC. ^*

SHOP ^*

WHSE ^*

FIELD ^*

OTHR ^*

# Sub-Contractors Employed

PEAK ^*

CURRENT ^*

# Sub-Contractors without safety programs

PEAK ^*

CURRENT ^*

# Company Owned Vehicles ^*

# Company Owned Trailers ^*

Does the company own or lease any facilities

OFC.

SHOP

WHSE

YARD

OTHR

DOES YOUR COMPANY;

Own or lease a rough terrain fork lift (zoom boom)?

Own or lease an Aerial Telescopic Boom Lift (genie lift)? ^*

Own or lease a Scissor Lift? ^*

Own or lease Pole & Clamp Scaffold Systems? ^*

Own or lease Pump Jack Scaffold Systems? ^*

DOES YOUR COMPANY HAVE TASKS THAT REQUIRE A WORKER TO;

Work at heights exceeding 3m? ^*

Yes

No

Use tools without safety guards? ^*

Yes

No

Work alone? ^*

Yes

No

Use hazardous materials, products or liquids? ^*

Yes

No

Cut materials made of silica? ^*

Yes

No

Cut materials made of fiberglass? ^*

Yes

No

Use flame / fire? ^*

Yes

No

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