Contractor Assessment Form

Business Type

Company or Trust
Partnership
Sole Trader

Company or Trading Name

ABN

Contact Person

Email

Phone

Street Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Is your postal address the same as your street address?

Yes
No

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Contractor OH&S Questionnaire

1. About your application

Are you or the business an existing Hazell Bros contractor renewing your accreditation?

Yes
No

Have you or the business previously been contracted by Hazell Bros?

Yes
No

What is the planned nature of the service/s to be provided to Hazell Bros for this application?

Please describe:

Approximate number of your employees that may directly undertake work for Hazell Bros :

Will you engage contractors to perform the above work for Hazell Bros?

Yes
No
Unsure

Provide the names of the subcontracting businesses:

Will your work involve any of the following activities:

Do you and/or the business and/or the workers possess the required relevant qualifications, endorsements, permits and licences for the proposed work? (attach copies if applicable)

Click or drag a file to this area to upload.

Examples: Electrical work/Plumbing/Asbestos (removal etc.)/Welding/Transportation & disposal of hazardous waste/Operation of heavy vehicles (>12t GVM), High Risk Work e.g. crane, forklift, lifting etc.

Is your business certified independently to any of the following:

Safety Management System Standard (e.g. AS 4801, OFSC)
Environmental Management System Standard (e.g. ISO 14001)
Quality Management System Standard (e.g. ISO 9001)

Please attach Safety Management System Standard

Click or drag a file to this area to upload.

Please attach Environmental Management System Standard

Click or drag a file to this area to upload.

Please attach Quality Management System Standard

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Do you have systems/processes in place for:

NOTE: You may be asked to provide evidence other than those already requested below

Please attach evidence of OH&S & Environment Management Policies:

Click or drag a file to this area to upload.

Please attach evidence of risk assessments for plant and equipment:

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Please attach evidence of risk assessments for storage and handling:

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Have you or your business had any:

Environmental incidents during the last three years, or received any environmental notices or persecutions from any authority?

Yes
No

Prior OH&S improvement and prohibition notices, or been prosecuted by any statutory authorities in the last three years?

Yes
No

3. Insurance Details

Do you have any of the following insurances:

Attach copies if applicable:

Click or drag a file to this area to upload.

Public Liability

Attach copies if applicable:

Click or drag a file to this area to upload.

Workers Compensation

Attach copies if applicable:

Click or drag a file to this area to upload.

Motor Vehicle

Attach copies if applicable:

Click or drag a file to this area to upload.

Professional Indemnity

Attach copies if applicable:

Click or drag a file to this area to upload.

Plant & Equipment

Attach copies if applicable:

Click or drag a file to this area to upload.

Industrial Special Risks

Attach if applicable:

Click or drag a file to this area to upload.

Cargo

Attach copies if applicable:

Click or drag a file to this area to upload.

Personal Accident

4. Fair Work Act 2009 and National Code of Practice for the Construction Industry

Explanatory Note

As an organisation which tenders and performs work that is Federally funded Hazell Bros is required to comply with the Code for the Tendering and Performance of Building Work 2016 (the Code). This requires all Contractors that may work for us on any Federally funded project to agree to abide by the Building Code 2016 in addition to the Fair Work Act 2009.

Where Contractors will only work on Hazell Bros privately funded constructions projects or other non-construction related work they will still need to commit to being Fair Work Act 2009 (FW Act) compliant.

Is the business compliant with the Fair Work Act 2009 and where applicable the Building Code 2016 as enacted under the Fair Work Building and Construction Industry (Improving Productivity) Act of 2016? *

Yes
No
NA (no employees)

If applicable provide evidence e.g. copy of letter from ABCC stating determination of compliance with section 11 of the code.

Click or drag a file to this area to upload.

By agreeing to undertake contract/supply you will be expected to have read and agree to comply with the Act and the Code where applicable. By submitting an expression of interest and agreeing to undertake the work/services you : a) will be deemed to have read; and b) agree that you must comply with the Fair Work Act and the Building Code where applicable. *

Yes
No
NA (no employees)

By checking yes to the above you agree that your consent has been given to the above statements. Fair Work information can be found here and the Code and Statements are available here.

5. Contractor Declaration

I hereby declare the information provided is a true and accurate reflection of the business management systems and processes. I agree to ensure compliance with the business management systems and processes and instruction issued by Hazell Bros during the course of work. I understand my responsibilities as a contractor to Hazell Bros, and will communicate these to persons under my control. *

By ticking this box, you are confirming that you are authorised to bind your company to the terms and conditions indicated.

Name of the person completing this:

Position held:

Date: