Life Saving Rules and QR Code for Safety Observations

1 - Company Information

Company Name:

Full Address / Incl. Postcode:

City

State/Province

Zip/Postal

Country

Telephone

Email

VAT Registration Number

Legal Status

Please notify of up to 5 Products or Services provided by your Company:

2 – Contact Information

Contact Name of Authorised Person:

Position in Company:

Telephone:

Email

3 - Authorisation

Can you please read the statements below and confirm acceptance before proceeding to section 4.

1.I confirm that I am an authorised person completing this form and to my knowledge all answers provided are true and
correct.

2.I agree to provide copies of:

Employers and Public Liability Insurance documentation, including Professional Indemnity if required.
Policies and procedures relating to modern slavery, environmental and sustainability including an energy
statement or roadmap highlighting how you intend to manage your energy performance. Health and Safety Policy and
relevant certifications. Statement or roadmap demonstrating your intentions or pathway to managing supply chain
tiering is required.
ISO Accreditations, i.e. ISO9001, 14001 and other relevant certifications and licenses relevant to your
industry. Including a screen shot from the HSE website as per the welcome letter.

3.I agree that in absence of my policies and procedures in point 2.2 above, I will agree to abide by the Ports Policies
and Management Standards. This information will also be filtered through to those persons attending site.

4.I agree to watch and adhere to the lifesaving rules as detailed below. Please scan the QR code for details. An
additional copy is provided within the welcome pack which must be shared with those persons attending site.

5. The QR code below will enable those persons on site to report a safety observation. I agree to share this with those
persons on site.

Authorised Person:

Position in Company:

Section 4 - Questionnaire

1. Insurance

A. Public & Product Liability Insurance to a minimum £5,000,000

Yes

No

Date of Expiry

B. Employers Liability Insurance to a minimum £10,000,000.00

Yes

No

Date of Expiry

C. Hired in Plant Insurance.

Yes

No

Date of Expiry

2. CIS Status & UTR Number

A. Are you currently a member of the Construction Industry Scheme?

Yes

No

B. Can you provide your Status 20% or Gross as well as your UTR Number? If yes, please provide.

Yes

No

C. If you are not registered with the Construction Industry Scheme we will deduct 30% of the element at source.

Yes

No

3. Tax Evasion / HMRC Compliance

A. Does your organisation have a tax evasion policy? (If Yes Go to question B if No go to question C)

Yes

No

B. Please provide a copy of your tax evasion policy and any additional evidence of your commitment to HMRC processes.

Yes

No

File Upload

Maximum file size: 134.22MB

C. To progress your application further you will be required to provide a policy / statement confirming the following:

(Further information as per the Criminal Finances Act 2017)

- VAT returns are submitted in time and in accordance with HMRC requirements.

- Corporation tax is paid in line with UK regulations.

- You do not request payment in cash in exchange for a discount.

- You do not request split payments to UK/Non UK Bank Accounts.

- You confirm that your organisation conducts its business activities in line with current HMRC processes.

- If you hire self-employed people within your business, you must confirm that you do not make ‘cash’ payments and that to the best of your ability you ensure they are paying tax liabilities to HMRC.

- You commit to ensuring that this statement/policy is shared with all employees. This is to ensure that your commitment is filtered throughout your organisation and they have awareness of the effect facilitating tax evasion will have.

4. Quality Management

A. Do you have a documented Quality Management System? (If Yes Go to question B if No go to question C)

Yes

No

B. Is it third party audited and certificated BS EN ISO 9001

Yes

No

C. Are you prepared to work to the Port's Quality Management system?

Yes

No

5. Health & Safety Management

A. Do you employ more 5 or more persons? (If No go to question B if Yes go to question C)

Yes

No

B. As you do not employ 5 or more persons and do not have a written Health and Safety Policy do you confirm any project under the control of Port of Tilbury London limited will be conducted in such a way that it complies fully with the Health and Safety Policy of Port of Tilbury London Limited.

Yes

No

C. Do you have a documented Safety Management System and Policy?

Yes

No

D. Is the Policy signed by the Managing Director?

Yes

No

E. Is it third party audited and certificated e.g. OHSAS 18001?

Yes

No

F. Have you appointed a competent person to provide Health and Safety Advice? If yes, please provide name and contact details.

Yes

No

Name

Telephone

G. Do you undertake the process of Risk Assessments?

Yes

No

H. Has your Company established Safe Systems of Work (Method Statements)?

Yes

No

I. Do you have a reporting system for reporting accidents?

Yes

No

J. Do you have a reporting system for near misses?

Yes

No

K. Has the Company ever been prosecuted by an enforcement authority (e.g. HSE or local authority)? To proceed you must provide evidence from the link below: Please refer to http://www.hse.gov.uk/enforce/index.htm

Yes

No

L. Has the Company ever been issued with an improvement notice or prohibition notice by an enforcement authority ((e.g. HSE or local authority)?

Yes

No

6. Waste Management – Please complete if applicable

A. Do you hold a Waste Carriers Licence?

Yes

No

B. Waste Management Licence (or Exemption Certificate)?

Yes

No

C. Hazardous Waste Licence?

Yes

No

D. Hauliers Operators Licence?

Yes

No

7. Environmental Management

A. Do you have a documented Environmental Management System? (If Yes Go to question B if No go to question C)

Yes

No

B. Is it third party audited and certificated to BS EN ISO 14001?

Yes

No

C. Are you prepared to work to the Ports Quality Management System?

Yes

No

8. Modern Slavery & Sustainable Procurement Strategy Policy / Statement

A. Do you have a Modern Slavery and Sustainable Procurement Policy / Statement? (If Yes Go to question B if No go to question C)

Yes

No

B. Can you provide a copy of your Modern Slavery and Sustainable Procurement Strategy Policy / Statement?

Yes

No

C. Have you read and understood the Port’s Modern Slavery & Sustainable Procurement Policy? (If Yes, Go to question D if No, please confirm you have read the Port’s document.)

Yes

No

D. Are you prepared to work to the Ports Modern Slavery and Sustainable Procurement Policy?

Yes

No

E. Do you audit your supply chain for Modern Slavery compliance? (If Yes, Go to question F if No, please go to question G.)

Yes

No

F. Please give details:

G. Are you prepared to?

9. Energy Management

A. Do you have a documented Energy Management Process/System? (If Yes Go to question B if No go to question C)

Yes

No

B. Can you provide a copy of your energy management plan? Please also refer to the Port’s statement.

Yes

No

C. If no you will be expected to provide a roadmap highlighting how you intend to manage energy in the future.

Yes

No

10. Tiering Compliance

A. Do you audit / manage your supply chain, in particular your tier 1 and tier 2 suppliers? (If Yes Go to question B if No go to question C)

Yes

No

B. Can you provide a statement demonstrating how this is performed.

Yes

No

C. If no you will be expected to provide a roadmap highlighting how you intend to manage tiering in the future.

Yes

No

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Life Saving Rules and QR Code for Safety Observations

Tilbury Contractor Evaluation Form

1 - Company Information

2 – Contact Information

3 - Authorisation

Section 4 - Questionnaire

1. Insurance

2. CIS Status & UTR Number

3. Tax Evasion / HMRC Compliance

4. Quality Management

5. Health & Safety Management

6. Waste Management – Please complete if applicable

7. Environmental Management

8. Modern Slavery & Sustainable Procurement Strategy Policy / Statement

9. Energy Management

10. Tiering Compliance

1 - Company Information

2 – Contact Information

3 - Authorisation

Section 4 - Questionnaire

1. Insurance

2. Accreditations - Please list all of your current accreditations (e.g. ISO9001, 14001)

3. Modern Slavery & Sustainable Procurement Strategy Policy / Statement

4. Energy Management

5. Tiering Compliance

6. Tax Evasion / HMRC Compliance