Complete one form per contractor before authorizing work to begin. Retain signed copy on file.
Form Version 1.0
Esper EHS ยท esper-ehs.com
Section 1 — Pre-Arrival Document Verification
Business LicenseVerify license is valid in the state(s) where work will be performed. For licensed trades (electrical, plumbing, HVAC, rigging, crane), confirm specific license type covers the work scope.
Certificate of Insurance (ACORD 25) — General LiabilityConfirm per-occurrence and aggregate limits meet contract minimums. Confirm policy dates cover the full period of work. Record limit: $________ per occurrence / $________ aggregate.
Certificate of Insurance — Workers' CompensationConfirm coverage includes all states where contractor employees will work. Note: Texas does not mandate workers' comp for most private employers; verify accordingly.
Additional Insured Endorsements (ISO CG 20 10 and CG 20 37)Request endorsement pages, not just the ACORD 25 checkbox. CG 20 10 covers ongoing operations; CG 20 37 covers completed operations. Confirm endorsements reference the current policy number.
Experience Modification Rate (EMR) LetterIssued by NCCI, WCIRB (CA), or applicable state bureau. Current EMR: ________ Threshold required: ________
Required Written Safety ProgramsPrograms required for this scope (check applicable): ☐ Fall Protection ☐ LOTO ☐ Confined Space ☐ Hot Work ☐ HazCom ☐ Other: ________
Personnel CertificationsVerify current (not expired) certifications for personnel assigned to the work. Record certifications verified and expiration dates on back or attached sheet.