New Form Submission from ECT Subcontractor H&S Prequalification - New Application
Section 1
Company legal name:
[field id="company_legal_name"]
Street Address:
[field id="street_address"]
Street Address Line 2:
[field id="address_line2"]
City:
[field id="city"]
State:
[field id="state"]
Zip Code:
[field id="zip"]
Website:
[field id="website"]
H&S Manager Name and Title:
[field id="HS_manager_name"]
H&S Manager Phone:
[field id="HS_manager_phone"]
H&S Manager Email:
[field id="HS_manager_email"]
Date:
[field id="date"]
Recent Service:
[field id="recent_service"]
NAICS Code:
[field id="NAICS_code"]
Certifications:
[field id="certifications"]
Certifications - Other:
[field id="certification_other"]
Section 2
TRIR 2024:
[field id="TRIR_2024"]
TRIR 2023
[field id="TRIR_2023"]
TRIR 2022:
[field id="TRIR_2022"]
DART 2024:
[field id="DART_2024"]
DART 2023:
[field id="DART_2023"]
DART 2022:
[field id="DART_2022"]
EMR 2025:
[field id="EMR_2025"]
EMR 2024:
[field id="EMR_2024"]
EMR 2023:
[field id="EMR_2023"]
Citations:
[field id="citations"]
Citations Summary:
[field id="citations_summary"]
Safety:
[field id="safety"]
Safety Summary:
[field id="safety_summary"]
H&S Program:
[field id="HS_program"]
H&S Program List:
HS_program_list
Section 3
Upload H&S Program Table of Contents:
[field id="upload_HS_program_TOC"]
Upload OSHA logs:
[field id="upload_OSHA_logs"]
Upload Citations Safety:
[field id="upload_citations_safety"]
Upload EMR Verification:
[field id="upload_EMR_verification"]
Upload Job Safety Analysis:
[field id="upload_Job_Safety_Analysis"]
Upload COI:
[field id="upload_COI"]
Upload W-9:
[field id="upload_W9"]
Upload Certifications:
[field id="upload_certifications"]
Message:
[field id="message"]
Signature Name:
[field id="signature_name"]
Signature Title:
[field id="signature_title"]
Signature Date:
[field id="signature_date"]
Scroll Up
ECT Subcontractor H&S Prequalification - Renewal Application
Section 1: Subcontractor Information
Company Legal Name:
Company legal name as it appears on the W-9:
Primary Mailing Address:
Street Address:
Address Line 2:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Website:
H&S Manager Information:
H&S Manager Name and Title (if you don't have one, please write "Not Applicable"):
H&S Manager Phone:
H&S Manager Email:
Current Date:
Date:
Recent Service:
Primary ECT contact(s) and office(s) most recently serviced:
NAICS Code(s):
Please list relevant NAICS Code(s):
Business Certifications:
If you possess any of the following Business Certifications, please check all that apply:
Small Business
Non-profit Organization
Businesses owned by economically disadvantaged individuals (DBE)
Woman Owned
Disability Owned
Veteran Owned
Service‐Disabled Vet owned
Black American owned
Hispanic American owned
Native American owned
Asian‐Pacific American owned
Subcontinent Asian American owned
HUBZone Certified
Other - Explain
Not applicable
If you selected "other," please specify below:
Please characterize the work you provided for ECT over the past 12 months.
Section 2: Document Uploads
Please provide your most current copy of the following items.
You may upload up to a total of 10 MB for all of your files; if you need to upload more or are experiencing difficulty uploading, please let us know and we will contact you directly. You may include up to 3 files per upload button. Hold down the command key to select multiple files from the same folder.
OSHA 2024 300/300A logs:
2025 EMR verification on insurance company letterhead:
Sample of completed Job Safety Analysis (similar for work to be performed with ECT):
Certificate of Insurance (COI) – Scroll to the bottom of the page to view our COI requirements
Business Certifications – If you answered yes to one or more of the Business Certifications in Section 1, please provide documentation:
Context and Explanation – Should any of the requested information not be available or need explanation, please provide an explanation here:
Next Steps
Once your renewal application is received, the information will be reviewed and you will be contacted either to confirm approval and active status in our system or to request additional or supplementary information such as HAZWOPER training certifications, procedural documentation, or other related information. To complete the application process, please complete the required signatures below.
"By signing below, I acknowledge the information provided is current and true and I have provided the support information requested or provided explanations why the information was not provided. Additionally, the submitting subcontractor agrees to follow ECT health & safety requirements and applicable state or Federal health & safety regulations."
Signature
Name
Title
Date
Submit
KP Test Form
Name:
Company:
Phone:
Email:
Please briefly explain your inquiry:
File Upload Section
You may upload up to a total of 10 MB for all of your files; if you need to upload more, please let us know and we will contact you directly.
You may include up to 3 files per upload button. Hold down the command key to select multiple files from the same folder.
File Upload 1:
File Upload 2:
File Upload 3:
File Upload 4:
File Upload 5:
File Upload 6:
File Upload 7:
File Upload 8:
Submit
ECT Inquiry
Name:
Company:
Phone:
Email:
Please briefly explain your inquiry:
Submit
ECT Subcontractor H&S Prequalification - New Application
Section 1: Subcontractor Information
Company Legal Name:
Company legal name as it appears on the W-9:
Primary Mailing Address:
Street Address:
Address Line 2:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Website:
H&S Manager Information:
H&S Manager Name and Title (if you don't have one, please write "Not Applicable"):
H&S Manager Phone:
H&S Manager Email:
Current Date:
Date:
Recent Service:
Primary ECT contact(s) and office(s) most recently serviced:
NAICS Code(s):
Please list relevant NAICS Code(s):
Business Certifications:
If you possess any of the following Business Certifications, please check all that apply:
Small Business
Non-profit Organization
Businesses owned by economically disadvantaged individuals (DBE)
Woman Owned
Disability Owned
Veteran Owned
Service‐Disabled Vet owned
Black American owned
Hispanic American owned
Native American owned
Asian‐Pacific American owned
Subcontinent Asian American owned
HUBZone Certified
Other - Explain
Not applicable
If you selected "other," please specify below:
Section 2: Subcontractor Health & Safety Information
Please provide the following data for the last three years below. If not applicable, please mark "NA" in the fields.
TRIR
– Total Recordable Incident Rate:
TRIR 2024
TRIR 2023
TRIR 2022
DART
– Days Away, Restricted, or Transferred:
DART 2024
DART 2023
DART 2022
EMR
– Experience Modification Rate:
EMR 2025
EMR 2024
EMR 2023
Citations/Safety
Has your company received a citation from OSHA or state equivalent, or other agency regarding an injury or environmental incident within the past 5 years?
Yes
No
If yes, please provide a brief summary:
Has your company experienced a work-related, OSHA defined severe injury including hospitalization, amputation, or death in the past 5 years?
Yes
No
If yes, please provide a brief summary:
H&S Program Information
Do you have H&S program information available about your company?
Yes
No
Not applicable
If you said yes, please check all that apply for your company.
We have a written H&S Program.
We hold Tailgate/Job Site Safety Meetings.
We have an Injury Management & Reporting Procedure.
We have a written Hazard Communication (HazComm) policy/program.
We have written H&S procedures for the work we may perform for ECT.
We prepare job-specific health & safety plans and job safety and hazard assessments.
We have a “Stop Work Authority” policy.
Section 3: Document Uploads
Please upload the following supporting documents.
You may upload up to a total of 10 MB for all of your files; if you need to upload more or are experiencing difficulty uploading, please let us know and we will contact you directly. You may include up to 3 files per upload button. Hold down the command key to select multiple files from the same folder.
H&S Program Table of Contents:
OSHA 300 and 300A logs for 2024, 2023, and 2022:
Explanation of any severe injuries, hospitalizations, deaths or citations in last 5 years:
On Insurance carrier letterhead, EMR verification for years 2025, 2024, and 2023:
Sample of completed Job Safety Analysis (similar for work to be performed with ECT):
Certificate of Insurance (COI) – Scroll to the bottom of the page to view our COI requirements
Current W-9 form (Signed) – A link to a fillable W-9 form is provided below.
Business Certifications – If you answered yes to one or more of the Business Certifications in Section 1, please provide documentation:
Context and Explanation – Should any of the requested information not be available or need explanation, please provide an explanation here:
Next Steps
Once your application is received, the information will be reviewed and you will be contacted either to confirm approval and active status in our system or to request additional or supplementary information such as HAZWOPER training certifications, procedural documentation, or other related information. To complete the application process, please complete the required signatures below.
"By signing below, I acknowledge the information provided is current and true and I have provided the support information requested or provided explanations why the information was not provided. Additionally, the submitting subcontractor agrees to follow ECT health & safety requirements and applicable state or federal health & safety regulations."
Signature
Name
Title
Date
Submit
DECLINE