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      NORTHWEST INDIANA BUSINESS ROUNDTABLE (NWIBRT)

                               2009
                     SAFETY AWARDS APPLICATION


Welcome to the 2009 Safety Award Application,

We are looking forward to receiving your application and seeing you at this year’s
banquet.

There are several changes from last year’s application. We would like to specifically
note the changes on page 6, which lists the criteria for the written portion of the
application. However, be sure to read each page carefully.

The Roger Walters Memorial Award was added in recognition of the life and work of
Roger Walters. Please go to the end of this award application for full details on this
award and the application process.




Thank you and work safely,
NWIBRT Safety Subcommittee




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             CRITERIA FOR APPLICATION EVALUATION

1. Submission of your three most recent Experience Modification Ratings (Submit a
   photocopy of your Insurance Company documentation to validate your application
   information.) If the photocopy of the Insurance Company documentation is not
   included, the application will not be accepted by NWIBRT).

2. Part 1: OSHA injury/illness (total cumulative for all locations) statistical data for the
   past 3 years. (Submit photocopies of the OSHA 300-A log summary sheets for the
   past 3 years to validate your application. If the photocopies of the summary sheets
   are not included, the application will not be accepted by NWIBRT).

3. Part 2: A typewritten synopsis of your safety management system (see page 6).

   (Parts #1 & #2 must be completed for consideration)

4. NWIBRT review of Applicant’s safety performance at NWIBRT sites.

5. Finalists are to be subject to a selected work site audit by NWIBRT.

6. Submit (2) two copies of the application packet.


ELIGIBILITY
1. All subscribers to the Northwest Indiana Business Roundtable are eligible to
   participate.
2. Any company that experienced a work-related fatality in the past year will only be
   eligible for the Innovation and the Roger Walters Memorial Awards.
3. Subscriber dues must be up-to-date




                                             1
                               AWARD CATEGORIES
RECOGNITION

   1. The Company’s (OSHA) Total Recordable Incident Rate and Days Away from
      Work (DAFW) must be below the most current national industry average for the
      company’s NAICS code as established by the Bureau of Labor Statistics. Those
      averages are:

                       NAICS 238*          NAICS 541*         NAICS 236*         NAICS 237*
                       (Old SIC 17)        (Old SIC 87)       (Old SIC 15)       (Old SIC 16)
Days Away From
 Work (DAFW)              2.7                  .5                2.1                2.2
Total Recordable
 Incident Rate            5.1                 1.1                4.0                4.2
      (TRIR)


*Your NAICS code must reflect the majority of your work. For information regarding the SIC to
NAICS code conversion refer to: http://www.naics.com/search.htm. Use the first 3 numbers of the
NAICS code. Call Jim Arendas at CAF, 219-764-2883, if you have questions.

   2. In addition, the company must have a continuously improved EMR for the last 3
      years, or have an EMR of .9 or less for the past year.


ACHIEVEMENT
The Company must first meet the criteria for Recognition Level.

   1. The company’s TRIR and DAFW Rate must be below the averages for our NWI
      Regional Contractor Community for the company’s NAICS code. This is
      determined by averaging the rates submitted during the annual statistics review
      of subscriber companies.

   2. In addition, the company must have an EMR of .9 or less for the past year.

   3. The company must demonstrate its safety management system by addressing
      the questions in Part 2 of the application.


EXCELLENCE
The Company must first meet the criteria for Achievement Level.

   1.   The company’s TRIR and DAFW as well as EMR must be below the averages of
        our NWI Regional Contractor Community for the company’s NAICS code.




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                   ADDITIONAL AWARD CATEGORIES

Progress Award

Any subscriber can submit an application to be considered for this award. The
company does not have to meet any of the criteria for the other award categories
to submit an application for the Progress Award. The subscriber must show an
improving DAFW and TRIR Rate for the past 3 years. If you are applying for this
award, fill out Part 1 completely and Part 2 of this application to the best of your ability.



Innovation Award

NWIBRT Member Companies will have an opportunity to nominate a contractor that
performs work on its site for this award, by submitting a letter describing the innovation.
As a contractor (subscriber) you also have the opportunity to submit a letter explaining
your innovative contribution that would qualify you for this award. Your company must
have played a proactive role in developing a new safety initiative at that site. You must
include a contact name and number for the Member Company that benefited from the
innovation. Companies being considered do not have to meet any of the criteria for the
other listed awards.



Contractor of the Year

Each contractor who meets the Excellence Award criteria will be considered for this
award. One Contractor of the Year award will be presented. The winner will be
selected by the NWIBRT Member Companies based on application evaluation, overall
contributions to the safety culture in Northwest Indiana and open discussion among the
Member Companies.



Roger Walters Memorial Award

This award will be presented to the safety representative that has demonstrated
extraordinary contributions to the safety of the workers in Northwest Indiana. The last
two pages of this application describe the award in detail along with the application
process.




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                                NAICS CODES

The eligible NAICS Code Groups are listed below:


Group #1:
NAICS 238 (Old SIC 17) – Specialty Trade Contractors


Group #2:
NAICS 541 (Old SIC 87) – Professional, Scientific & Technical Services


Group #3:
NAICS 236 (Old SIC 15) – Construction of Buildings


Group #4:
NAICS 237 (Old SIC 16) – Heavy & Civil Engineering Construction


Notes:
Your NAICS code must reflect a majority of your work. For information regarding the
SIC to NAICS code conversion refer to: http://www.naics.com/search.htm. Use the first
3 numbers of the NAICS code. Call Jim Arendas at CAF, 219-764-2883, if you have
questions.




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                                                     NWIBRT Part 1
                                      SAFETY AWARDS APPLICATION

COMPANY NAME: _____________________________________________________
ADDRESS: ___________________________________________________________
CITY: ____________________________ STATE: ____________ ZIP: ___________
TELEPHONE NUMBER: _______________ FAX NUMBER: _______________
NAICS Category: _______________________ (Refer to page 4 for NAICS Information)

EMR Information:
Submit Your Most Recent Three Years Workers Compensation Experience
Modification Rates.
**ATTACH COPIES OF INSURANCE COMPANY DOCUMENTATION.
                                         2007                        2008                         2009
Interstate Experience
Modification Rate

OSHA 300 Log Information:

**ATTACH COPIES OF OSHA 300 Log Summary Sheets.
                                  2007            2007              2008             2008               2009    2009
                                  NWI            National*          NWI             National*           NWI    National*

Total No. of Fatalities

Total No. of Cases with
Days Away From Work
Total No. of Cases with
Job Transfer/Restriction
Total No. of Other
Recordable Cases

Total Hours Worked

+
DART Incident Rate

Total Recordable
Incident Rate
         Total Recordable Incident Rate (TRIR) = ^Number of cases x 200,000 hours of exposure
                                                            Total Hours Worked
* All awards based on local frequencies. National numbers for reference only (other than fatalities).
+"DART" stands for "Days Away, Restricted or Transferred". A DART case is a subset of OSHA recordable cases where
the injury/illness is severe enough that the individual loses time away from his/her job by being away from work, on
restricted duty, or is transferred to another job function because of the injury.
^Number of cases is the total of the first 4 rows.

Prepared By and Title (print): ________________________________________
Signature: ________________________________________ Date:__________
CEO/President (Signature): ________________________________________
CEO/President (Printed): ________________________________________
                                                             5
                                   NWIBRT Part 2
                          SAFETY AWARDS APPLICATION


1. NAICS Code (You Must Select 1) ______________ Description of Contractor
   work/service provided:

2. List three clients from the Business Roundtable Member Companies to
   contact for a reference of your safety practices and performance:

Name(s)                 Company                  Telephone No          Email




3. Provide a maximum of (5) five double-spaced typewritten pages describing
   your safety management system including the following criteria (do not
   include safety manuals, booklets, etc.):
       a. Management accountability and commitment (include statement or policy)
       b. Written safety and health programs (include who maintains the program
          within your organization)
       c. Orientation for new employees and on-going safety training for all employees
          (include how you determine the effectiveness of your training)
       d. Site safety meetings (include frequency, duration, who conducts, attends, and
          how meetings are documented)
       e. Conformance to safe work practices (include accountability for safe and
          unsafe behavior)
       f. Incident reporting/investigation & use of incident statistics to improve safety
          performance (include how the statistics are used)
       g. How unsafe conditions are reported and resolved
       h. New program innovations that you implemented in the last year to improve
          your safety culture and reduce injuries & illnesses

4. If your firm is selected as a finalist, who is to be contacted to arrange a work
site audit?
      Name: ____________________________________
      Title: _____________________________________
      Phone Number: ____________________________
      Email: ____________________________________



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Instructions for Filing Application

Send completed applications to

NWIBRT
c/o Jim Arendas
The Construction Advancement Foundation
6050 South Port Rd., Suite A
Portage, IN 46368

NOTE: Submit (2) two copies of the application packet.

All award applicants are required to complete the application in full for acceptance, and
have the application signed off by the Chief Executive Officer or President of the
contractor firm.


Deadline for Filing Application

          Applications must be postmarked
           before midnight March 19, 2010

Questions
Any questions about the application process can be directed to:

      Jim Arendas - Construction Advancement Foundation - 219-764-2883



  The awards will be presented at the Annual Recognition Ceremony
  Dinner Banquet at the Avalon Banquet Facility on Friday May 14th,
                                2010.




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                  ROGER WALTERS MEMORIAL AWARD
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       In recognition of Roger's service and dedication to the field of safety the NWIBRT
       would like to introduce the First Annual Roger Walters Memorial Award. The
       award will be presented to the safety representative that has demonstrated
       extraordinary contributions to the safety of the workers in Northwest Indiana. We
       are not looking for a single great act but a person whose everyday diligence and
       dedication to their field creates a working environment that mirrors the slogan
       “Never Give Safety A Day Off”.

       Roger Walters took safety seriously. It was not just a job to him, it was his life. He
       felt responsible for those who worked under his care and helped out other safety
       representatives by correcting situations at their site or letting them know of
       problems. I am sure that there are people out there who owe their lives to him,
       because they had him looking out for their well being and safety. He spoke up,
       even when in difficult situations, because he couldn't just “let it go”. It was just
       not in his constitution to walk away with an unresolved situation. He was always
       honest and truthful and fair. He always took the time to talk things over and
       earned the respect of all those who worked with him over the years. He was
       always looking out for everyone. He was the one you could always count on to
       know the answer or who could direct you to the right source. And, he didn't stop
       with safety at work, he lived it every day, at home, when out with his family, on
       vacation, and really in everything he did. Just listening to his stories made it real,
       he made you feel like you were there, and that you too could have the dedication
       and courage to do the things he took for granted. He was a selfless champion and
       a hero and he will be missed.

       We ask that the company manager take careful consideration when nominating a
       safety representative from their company. The nominee must have at least 3 years
       experience and at least 50% of his/her job must be dedicated to safety. We also
       require that the nominee work 3 years for a company located in Northwest
       Indiana. The application must include one typed page describing why this safety
       representative should receive this award. We require that you include at least 3
       recommendations from hourly employees. Feel free to include non-work related
       activities that you feel would be relevant (EMT, volunteer, etc.).The next page
       contains the application. We ask that you fill it out and return it with your Safety
       Awards Application. The use of the form is not required but make sure all
       necessary information is contained on any separate sheets.


       Thank You,
       NWIBRT Safety Sub-Committee


                                                 8
         ROGER WALTERS MEMORIAL AWARD
                  APPLICATION


Company: __________________________

Address: __________________________

Contact Name: __________________________

Contact Title: __________________________

Contact Phone No: __________________________

Nominee Name: __________________________

Nominee Title: __________________________

Years of Service with Company: __________________________

Years of Service in the Safety Field: __________________________



Attach the following to complete the application:

   o (1) One typed page describing why this award should go to the
     nominee
   o (3) Three recommendations from hourly employees



Please mail your nominee’s application to the following:

NWIBRT
c/o Jim Arendas
The Construction Advancement Foundation
6050 South Port Rd., Suite A
Portage, IN 46368




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