HomeMy WebLinkAboutResolution No. R19-24RESOLUTION NO. R19-24
A RESOLUTION ADOPTING A SAFETY POLICY FOR THE CITY OF LAUREL.
WHEREAS, the City of Laurel Staff prepared a Safety Policy for the City of Laurel in order
to provide its employees safe and healthful working conditions; and
WHEREAS, the City of Laurel is required to comply with the Federal Occupational Safety
and Health Administration (OSHA) Regulations that have been adopted by the State of Montana and
the Safety Policy will enable the City to remain in compliance with such regulations; and
WHEREAS, City staff worked in concert with employees, department heads, and the Mayor
who all recommend the City Council adopt the same.
NOW, THEREFORE, BE IT RESOLVED by the City Council ofthe City of Laurel, Montana,
that the City Council hereby adopts the attached Safety Policy for the City of Laurel.
Introduced at a regular meeting of the City Council on June 18, 2019, by Council Member
McGee.
PASSED and APPROVED by the City Council of the City of Laurel, Montana, this 18th day
of June 2019.
APPROVED by the Mayor this 18th day of June 2019.
CITY OF LA L
Thomas C. Nelson, Mayor
ATTEST:
Be anY'L'knRLe\City Clerk/Treasurer
Approved -as to form:
Sam S. Painter, Civil City Attorney
R19-24 Adopt Safety Policy
Effective Date: June 18, 2019
Adopted via Resolution No. R19-24
SAFETY
POLICY
Laurel, MT Safety Policy
Review and Approval
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Laml,MT Safety Policy
TABLE OF CONTENTS
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Laurel, MT Safety Policy
Pg
Section
1. INTRODUCTION.............................................................................................3
Section
2. MANAGEMENT STATEMENT OF COMMITMENT ...............................
3
Section
3. RESPONSIBILITIES
3.1 Management........................................................................................................
4
3.2 Supervisors..........................................................................................................
4
3.3 Employees...........................................................................................................
4
3.4 Safety Officer......................................................................................................
5
Section
4. SAFETY TRAINING
4.1 All Employees.......................................................................................................
6
4.2 New Employee Safety Orientation.......................................................................
6
4.3 Annual Safety Training.........................................................................................
6
4.4 Job -Specific Safety Training................................................................................. 6
Section
5. SAFETY COMMITTEE
5.1 Organization.......................................................................................................... 7
5.2 Duties.................................................................................................................... 7
5.3 Meetings................................................................................................................ 8
Section
6. SAFETY RULES AND REGULATIONS
6.1 General Safety Rules.............................................................................................
9
6.2 Lockout/Tag Out...................................................................................................
9
6.3 Lifting Procedures.................................................................................................10
6.4 Office Safety.........................................................................................................10
6.5 Office Ergonomics................................................................................................
11
6.6 Working in Extreme Weather Conditions.............................................................12
6.7 Confined Space Entry...........................................................................................
12
6.8 Personal Protective Clothing & Equipment..........................................................13
6.9 Hearing Conservation/Protection..........................................................................
14
6.10 Respiratory Protection.........................................................................................14
6.11 Bloodborne Pathogens.........................................................................................14
6.12 Forklift Operations..............................................................................................15
6.13 Fall Protection.....................................................................................................15
Section
7. DISCIPLINARY POLICY...............................................................................17
Section
S. ACCIDENTANCIDENT REPORTING.........................................................17
Section
9. TRAINING REQUIREMENTS FOR SAFETY & HEALTH
9.1 Required Training................................................................................................
19
9.2 Available Training Programs..............................................................................19
Section
10. EMERGENCY EVACUATION & RESPONSE PLANS..............................19
Section
11. SAFETY & HEALTH COMMUNICATION.................................................
19
Section
12. FORMS
Hepatitis B Vaccine Declination.................................................................................20
SafetyOrientation.......................................................................................................
21
Incident Reports and First Report of Injury/Occupational Disease ............................
22
Report of Workplace Hazard......................................................................................
23
Workers' Comp Incident Report .................................................................................
25
Liability or Property Incident Report (Company)..........................................27
Liability or Property Incident Report (Individual)........................................30
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Laurel, MT Safety Policy
SECTION 1 INTRODUCTION
It is the policy of the City of Laurel to provide and maintain safe and healthful working conditions, routine safety
training and education, and to follow practices that will safeguard all employees and result in safe working
conditions and efficient operation.
When a person enters the employ of the City, they have a right to expect that they will be provided with a proper
place in which to work, and proper equipment with which to do their job, so that they will be able to devote their
energies to doing their work without danger to their life and health. Only under such circumstances can the
association between employee and employer be mutually profitable and harmonious. It is the City's desire to provide
a safe place to work and safe equipment to use as well as to establish and insist upon safe methods and practices at
all times.
Safe practices, on the part of City employees, must be part of all operations. This responsibility is required of each
official and employee who conducts the affairs of the City, no matter in what capacity they may serve. The idea of
job production and safety must be inseparable.
Employee cooperation regarding safety matters will be considered a condition of employment. The supervisor is
responsible for the safety and well being of their staff in the workplace. This responsibility can be met only by
working continuously to promote safe working practices among all employees and to maintain property and
equipment in safe operating condition.
SECTION 2 MANAGEMENT COMMITMENT
The purpose of the Safety Policies and Procedures is to provide a management system for the prevention of
occupational injuries and illnesses and compliance with regulations concerning occupational safety and health.
Safety Policies and Procedures assign safety responsibilities, promulgate Citywide procedures, and set minimum
safety program requirements for issues involving City departments. Additional department and/or division specific
policies and procedures will be issued to implement safety programs.
This Safety Plan provides general direction for the administration of occupational safety and health management for
the City. It is intended to meet the letter and spirit of the Montana Safety Culture Act and achieve full compliance
with federal Occupational Safety and Health Administration (OSHA) regulations, as adopted by the State of
Montana, governing workplace accident prevention programs.
Separate Safety Policies and Procedures will be issued as needed to address specific safety and health issues or to
meet the regulatory requirements for written compliance programs.
The City is committed to providing dependable, economical services to the public. The City recognizes its
employees as the most important resource in meeting that commitment and is dedicated to providing a safe and
healthful work environment.
The City recognizes that some accidents are caused by unsafe conditions or unsafe behavior and strives to eliminate
unsafe acts and conditions systematically. In meeting that goal, it is the policy of the City to:
• Provide a safe workplace including facilities, equipment, tools and vehicles that meet safety and health
standards and practices.
• Define and implement safe work practices to address hazards unique to specific job assignments.
• Train employees in the safe performance of assigned jobs.
• Monitor workplace conditions and employee behavior to ensure compliance with the City of Laurel
Safety Plan, as well as individual department and division safety and health requirements.
• Involve all employees in a systematic effort to recognize, report and correct hazardous conditions and
practices.
• Investigate and analyze accidents to identify and eliminate the unsafe conditions and behaviors that
caused the accidents.
The management staff will not tolerate actions that jeopardize the safety and health of employees or the general
public or actions that risk non-compliance with established safety and health regulations. Employees who violate
City, departmental, and/or divisional rules are subject to the disciplinary policies. Fulfillment of safety-related
responsibilities will be considered a factor in performance reviews and promotions.
Laurel, MT Safety Policy
SECTION 3 RESPONSIBILITIES
All City employees share in the responsibility to establish and maintain a safe working environment. The following
responsibilities are guidelines to establish accountability for the Safety Program. These responsibilities are not in
any way intended to limit innovation or initiative on the part of any employee who is working toward the goal of
achieving a safe workplace.
3.1 Department Heads, Superintendents, Upper-level management
a. Ensure the design, maintenance of facilities, tools, equipment, and vehicles meet or exceed established
safety standards.
b. Approve and ensure usage of policies, procedures and safe work practices for department occupations,
tasks, and locations.
c. Approve and ensure usage of safety -training requirements for department employees based on their
occupations, work locations, and tasks. (See 3.2.b.)
d. Review department Accident Investigation Reports, Incident Reports and department injury and illness
trends. Resolve corrective action issues that are beyond the scope of the supervisor to accomplish.
e. Review workplace inspections with Supervisors and direct appropriate corrective action to achieve a safe
work environment.
3.2 Supervisors
a. Establish policies, procedures and safe work practices for department/division occupations, tasks, and
locations.
b. Establish safety -training requirements for department/division employees based on their occupations, work
locations, and tasks.
c. Monitor workplace conditions and employee work behaviors through regular, scheduled inspections and
frequent observation of the work environment.
d. Enforce City and departmental tool, equipment, and vehicle standards and rules governing the workplace
behavior of employees.
e. Ensure employee participation in City and department required safety training. Recommend additions,
deletions, and modifications of safety training requirements or training programs based on observed
workplace conditions and employee work behavior.
f. Investigate accidents involving employee injury or illness and/or damage to vehicles or other City property.
Determine the facts and causes of the accident. Implement or recommend corrective actions for the purpose
of preventing future, similar occurrences.
g. Encourage employee involvement in safety hazard recognition and act on hazard elimination and hazard
control suggestions from the safety committee and individuals.
h. Identify unsafe work conditions and unsafe practices. Correct immediate hazards within ability or report
them to immediate supervisor upper management and/or and report recurring conditions to upper
management and/or safety committee.
3.3. All Employees
a. Abide by the City and department/division work practices established for specific job assignments and
occupations.
b. Report occupational injuries, illnesses and near misses immediately to their supervisor. Follow supervisor
instructions for obtaining first aid and/or medical attention. Participate in accident investigations as
requested by the supervisor.
c. Participate fully in safety training. Suggest improvements in safety training requirements or programs to the
supervisor or the safety committee.
d. Identify unsafe work conditions and unsafe practices. Correct hazards or report them to the supervisor or
safety committee as appropriate.
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Laurel, MT Safety Policy
e. All employees are required to acknowledge that they have received and read and that the employee
understands the policies contained therein. That manual includes, but is not limited to, several sections on
the safety of City employees such as vehicle use, reporting accidents or injury, safety data sheets, workers
compensation, early return to work, smoking, alcohol and drug use, housekeeping and cell phones. By this
reference, those policies are considered a part of this Safety Policy.
3.4. Safety Officer
a. Assist and advise all levels of management in establishing an effective safety program.
b. Provide new employee general safety and health training/orientation.
c. Coordinate with clerical staff that accident and incident records for workers' compensation purposes are
maintained and filed appropriately.
d. Plan and coordinate inspections, committee meetings, and assist management in all areas of safety and
health.
e. Act as permanent Chairperson and provide support for the Safety Committee.
f. Report committee members' unexcused absences to supervisors and/or City Administrator as appropriate.
Laurel, MT Safety Policy
SECTION 4 SAFETY TRAINING
4.1. All Employees
It is the policy of the City to provide all safety training prescribed by regulatory requirements and to ensure that all
employees understand the hazards to which they may be exposed and how to prevent harm to themselves and others
No employee is expected to undertake a job until he or she has received instructions on how to do it properly and
has been authorized by their supervisor to perform that job. Employees are expected to participate and cooperate
fully in training programs and to accept and follow established safety and health precautions.
Each worksite presents a unique training challenge. Therefore, each department/division is expected to specify and
provide safety training that is tailored to each employee's occupation, task and job location. To the extent possible,
safety training should be integrated into general job training, rather than treated as a separate issue.
All safety-related training must be documented; the records are to be maintained by the Safety Officer.
Documentation shall include a list of employees in attendance, date, and the name of the trainer and an outline of the
topics discussed or category of safety training delivered.
4.2. New Employee Safety Orientation
The purpose of new employee safety orientation is to provide the employee with information about:
• The general hazards and safety rules of the worksite,
• Specific hazards, safety rules and practices related to the employee's work assignments, and the
employee's role in emergency situations
This training shall take place as soon as practical, preferably within 2 months of the employee beginning assigned
duties.
4.3. Annual Safety Training
Annual safety training shall be conducted and be of sufficient duration and content to assure continued safe
operations. See Section 9.1
4.4. Job -Specific Safety Training
Job -specific safety training includes personal on-the-job instruction, safety meetings or formal classroom instruction
intended to enhance the safety of specific tasks or occupations. Some job -specific training is prescribed in City of
Laurel/Departmental Policies and Procedures or in regulatory requirements. Departments and divisions will provide
additional training as necessary to improve employee knowledge of safety rules, procedures, and safe practices. The
intent of this policy is that safety training will enhance the employee's understanding of workplace hazards and the
prevention of occupational injuries and illnesses, rather than to prescribe the specific format of the safety training.
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Laurel, MT Safety Policy
SECTION 5 SAFETY COMMITTEE
5.1 Organization
The City encourages and expects employee participation in the Safety Program. The City Safety Committee shall
consist of a person or persons from each of the following groups:
Fire/Ambulance
Police
Office Workers*
Library
Public Works
Planning
Waste Water Treatment Plant
Water Treatment Plant
Utility Maintenance
Streets
Solid Waste
Union Representatives
*This group will include all positions whose jobs are performed predominantly at a desk, such as Administrative Assistant, secretary or
other office workers.
5.2 Duties
The Safety Committee is an advisory body organized to bring employees and management together in a cooperative
effort to foster a safety culture and reduce on the job injuries and illnesses in the workplace. The Committee may
make recommendations about the following education and communications matters:
• Assessing and communicating hazards
• Communicating with employees regarding safety committee activities
• Educating employees on safety-related topics
• Motivating employees to create a safety culture in the workplace
The Committee may also recommend specific actions concerning:
• Development of safety rules, policies, and procedures
• Control of hazards
• Periodic evaluation of the safety program
• Inspection of the workplace
• Development of safety training and awareness topics
• Keeping job -specific training current
The City Safety Committee is encouraged to be innovative in its approach to achieving those goals within the
following guidelines:
1. A safety committee meeting must have a quorum present to take any action. Items may be discussed, and
information exchanged though no action may be taken until a quorum is present. A quorum is eight
members.
2. The safety committee must document its meetings in minutes to include:
a. Date, time and location of the meeting
b. A list of members present
c. The topics or issues discussed
d. The recommendations or suggestions made
3. Distribution of the minutes will include:
a. All safety committee members
b. All Department Heads
c. City Manager
d. Posted for each Department
4. The safety committee will be provided appropriate support staff, meeting space and resources (such as
photocopies).
5. Department committees are not required. Supervisors will be required to provide staff with necessary safety
training and ensure they attend any Citywide training offered.
6. Other than Public Safety departments, attendance rosters for all training will be forwarded to the
appropriate clerical office for placement in personnel files and copies retained by Safety Officer for review
by City Administrator, Mayor, and Council members.
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Laurel, MT Safety Policy
7. Safety duties will be covered in job descriptions. Department heads or supervisors will be responsible for
including such duties in job descriptions and covering with employees.
5.3 Meetings
1. Members must attend all meetings unless excused. The department head or supervisor will notify the Safety
Officer via email when there is an excused absence and identify any designated substitution.
2. The committee will meet at least quarterly.
3. If a current member does not desire to remain on the committee, the Department Head shall appoint a
replacement. That replacement shall come from the same employee pool as those whom that position
represents.
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Laurel, MT Safety Policy
SECTION 6 SAFETY RULES & REGULATIONS
As a basis for employee responsibilities and participating in the City's Safety Policy Program, the general safety
rules listed below will apply to all employees. Your cooperation in complying with these rules and all other safety
responsibilities will be appreciated and expected.
6.1 General Safety Rules
1. Seek medical attention, if necessary, for any accidents resulting in an injury. All accidents must be reported
to the supervisor within 24 hours.
2. Report unsafe conditions, procedures, and practices to your supervisor immediately.
3. The use or possession of alcohol, illegal drugs or other controlled substances on the job is prohibited.
4. Smoking is permitted in designated areas only.
5. Each employee is responsible for good housekeeping. Keep your work area in a clean, uncluttered state. Do
not walk by a situation of poor housekeeping if it can be easily corrected or needs immediate attention such
as spills on floors, ice on steps and so on.
6. Obey all warning tags and signs. They are there because hazards exist.
7. When purchasing any hazardous chemical, cleaning supplies or paint products request a Safety Data Sheet
for the product and ensure that it is included in the SDS binder.
8. No employee should take chances on the job which could endanger their personal safety and health or the
safety and health of co-workers or others.
9. Do not operate machinery or use tools you are not qualified to use.
10. Do not enter hazardous areas you are not authorized to enter.
11. Use all personal protective equipment and devices required and provided.
12. If an established job procedure must be deviated from, supervisory approval must be obtained and an
alternative, temporary job procedure must be agreed upon. This alternative job procedure must not create
any new or additional hazards or unnecessarily expose employees to hazards.
13. Become familiar with and conduct your work activities in accordance with these general safety rules and
other specific safe operating procedures which are applicable.
14. Refrain from fighting, horseplay, or distracting fellow workers.
15. Follow proper lifting procedures at all times
16. Wearing of safety restraints when riding/driving a City Vehicle is mandatory if so equipped.
17. Know the location of fire/safety exits and evacuation procedures.
18. Participate in Safety Training.
19. When operating City vehicles or equipment, drivers must operate/drive safely and prudently.
20. When using cell phones in a City vehicle, pull ovef and stop on the side of the road or utilize a hands-free
device.
21. Above all be ALERT and be RESPONSIBLE! Your safety and health depend on it.
6.2 Lock Out / Tag Out
OSHA Standard 29 CFR 1910.147 requires that hazardous energy must be controlled during service or maintenance
of machines and equipment. Lockout and tag -out (LO/TO) procedures are necessary to protect workers from electric
shock, accidental start-ups, or other release of energy.
Every department that has employees performing maintenance where there is exposure to hazardous energy must
have:
• locks and/or tags and lockout devices that are not used for anything else
• procedures for performing such maintenance specific to their area
• training for all employees involved in maintenance activities
Basic Rules for Using Lockout/Tag-out
1. All equipment shall be locked out or tagged out to protect against accidental or inadvertent operation
when such operation could cause injury to personnel.
2. Do not attempt to operate any switch, valve, or other energy isolating device when it is locked out or
tagged out.
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Laurel, MT Safety Policy
3. Lockout/tag-out devices shall be removed only by the employee who applied the device.
[EXCEPTION: In cases where the authorized employee who applied the lock or tag is not available,
the lock or tag may be removed by the direct supervisor in charge of either the department involved or
the maintenance crew that placed the LO/TO or under his/her direct authority. The employee whose
lock was removed must be notified by the supervisor prior to returning to the work site].
4. The division supervisor will inform outside contractors of the elements of the City's lockout/tag-out
program and ensure that work efforts are fully coordinated, and that compliance is achieved.
5. Where shift or personnel changes occur before the lockout/tag-out is terminated, a changeover period
will be established by the supervisor. Departing employees will remove their locks and/or tags and
arriving employees will apply their locks and/or tags. The supervisor will fully inform arriving
employees on the scope and stage of the work.
All accidents involving lockout/tag-out must be reported immediately to the supervisor in charge.
6.3 Lifting Procedures
Proper manual lifting techniques will protect your back by keeping it in its strongest position during stress. These
techniques are not natural movements and must be learned and practiced. Keep the basic principles in mind every
time you lift, no matter how small the load.
1. Assess the load before you lift. Know your limitations. Get help for heavy or bulky objects.
2. Spread feet shoulder -width apart to give yourself a solid base of support.
3. Place your feet as close as possible to the base of the object you are lifting with one foot slightly in
front of the other.
4. Bend with the knees and maintain the natural curve in the back during the entire lifting operation
(weightlifter position).
5. Get a good grip on the object and primarily use the leg muscles, not the back, to lift the load.
6. Move your feet to change directions -- avoid twisting.
7. Don't overdo. Take frequent breaks for repetitive lifts. Your back is more susceptible to injury when
tired.
6.4 Office Safety
Office work is more dangerous than is commonly supposed and serious injury accidents can occur during normal
office routine. Good housekeeping and proper storage are important factors in office safety and fire prevention.
Proper lifting techniques will prevent most back injuries. Offices are typically inspected for safety compliance less
often than other areas. It is important that you correct or report unsafe conditions to your supervisor.
1. Every employee is responsible for keeping his or her work area clean and orderly. Even a pencil or
paper clip can cause a slip or fall.
2. Open doors slowly. Be extra cautious when you come to a door that can be opened in your direction.
Slow down when you come to a "blind" corner.
3. Do not read while walking.
4. Proceed with caution. Haste when walking between desks can result in bruises and falls.
5. Keep electrical cords and other tripping hazards out of aisle ways, and do not run cords through
doorways.
6. Keep file, desk and table drawers closed when not in use. Close them before you leave them.
7. Never open more than one file drawer at a time. The entire cabinet may tip over.
8. Be careful when opening drawers to full extension in case there is no locking device.
9. Load file cabinets and bookcases with the heaviest items in the bottom to prevent tipping.
10. Maintain office tables, desks and chairs in good condition and free from sharp corners, projecting
edges, wobbly legs, etc.
11. Use chairs sensibly. Do not tilt chair or slump back, which may cause the chair to slip or break.
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Laurel, MT Safety Policy
12. Never use a chair, desk or other office furniture for a step stool or ladder.
13. Recognize the potential for puncture injuries with message spindles. Consider not using spindles,
bending the point horizontally or covering the point.
14. Keep the blades of paper cutters closed when not in use.
15. Keep razor and "exacto" blades covered. Report even minor injuries and take precautions to avoid
infection.
16. Be sure that cords and plugs on all electrical equipment are in good shape. If a machine causes a shock
or starts smoking, unplug it immediately and report it to the supervisor. Do not overload outlets.
17. Do not attempt any electrical repairs.
18. Use handrails when ascending or descending stairs. Don't carry a load that restricts vision.
19. Walk, do not run. When walking in hallways, keep to the right, especially at corners.
20. Be careful in front of doors that open outward and open doors slowly.
21. Avoid spilling or splashing liquids on the floor. If you spill it, clean it up. Provide barricades or other
warnings as necessary.
6.5 Office Ergonomics
Ergonomic injuries include tendonitis, carpal tunnel syndrome, lower back pain and other disorders that involve pain
and damage to muscles, tendons, and nerves in the back, neck, shoulders, elbows, wrists, and hands. These
musculoskeletal problems are referred to as cumulative trauma disorders (CTD) or repetitive motion injuries and are
generally caused by:
• making the same motion over and over
• staying in the same position too long
• working in a position that puts stress on muscles and joints
• working with tools and equipment that doesn't fit your body
• using excessive physical force
• exposure to vibration over a long period of time
You can help prevent CTD's by avoiding awkward body positions:
• adjust your workstation before you begin working
• maintain the natural curve in your back while sitting, standing and lifting
• keep your wrist straight as much as possible while typing or doing other repetitive tasks
• take breaks from repetitive motion tasks by switching periodically to other tasks
• use the right tools for the job, especially when they are used often or for long periods of time
If you spend a lot of time at a computer workstation:
• Position the keyboard so that the wrists are kept straight — use a wrist rest if necessary. Your elbows
should be at about the same height as the keyboard.
• Sit with your back in a neutral posture, maintaining the natural curve, with feet on the floor and thighs
parallel to the floor. [Adjust the chair height and use a footrest if necessary]
• Position the screen just below eye level and about 18-24" away to prevent neck and shoulder strain
[the screen should be lower if you use bifocals]
• Change positions, stretch and take "mini -breaks" periodically
Pay attention to early signs of cumulative trauma disorders and make adjustments in your workstation or the way
you do your work. Report the symptoms to your supervisor and work together to correct the causes of the injuries.
Early indicators of CTD, which usually occur in the hands, arms, shoulders, neck, and back, include:
• stiffness or soreness
• aches and pains
• numbness or tingling
• swelling
• burning sensation
• reduced strength
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Laurel, MT Safety Policy
6.6 Working in Extreme Weather Conditions
Montana's climate may be severe, and conditions may change rapidly. Hot weather and exposure to the sun present
the potential for heat stress and sunburn. Cold conditions can lead to hypothermia or frostbite, either of which can be
fatal in the worst cases. Employees are expected to monitor weather and be prepared to protect themselves against
its effects.
In general, employees will provide clothing as protection from severe weather conditions, if it is the type of clothing
that may be used both on and off the job. Examples include coats, hats or caps, boots, and gloves. Departments may
provide some or all of such clothing. Check with your supervisor.
Hot Weather Guidelines
1. Dress for conditions -- lightweight, light-colored loose clothing is best. Wear a hat with a wide brim if
you're out in the sun.
2. Use sunscreen.
3. Reflected sun is even more potent than direct exposure. Be particularly careful of sun exposure on
cloudy days and near water, concrete or sand.
4. Eat a well-balanced diet, but try to stay away from hot or heavy foods. Do not take salt tablets or other
salt supplements without a doctor's recommendation.
5. Drink plenty of fluids. Don't wait until you're thirsty. The best fluid replacement is water. Avoid
alcohol and caffeine.
Cold Weather Guidelines
1. Dress for the conditions in layers of loose, dry clothing. Cotton or wool clothing with a waterproof
layer over it is very effective.
2. Change clothing right away if you get wet.
3. Cover your head and face.
4. Wear shoes and gloves designed for cold weather.
5. Keep moving when you're in the cold.
6. Return to a warm vehicle or take regular breaks in warm areas frequently.
For hypothermia, get medical help quickly and keep the person covered with blankets. Don't use hot baths, electric
blankets or hot water bottles. For frostbite, get medical help and warm the body part with blankets or warm (not
hot!) water. Don't rub, use heat lamps or hot water bottle or go near a hot stove. Don't break any blisters that form.
6.7 Confined Space Entry
DO NOT ENTER HAZARDOUS AREAS YOU ARE NOT AUTHORIZED TO ENTER OR FAIL TO
HAVE A PERMIT TO DO SO.
Very few work situations have as much potential for serious safety hazards as confined spaces. The atmosphere in a
confined space may have insufficient oxygen to support life or may be toxic, flammable or explosive. The lack of
ventilation in confined spaces causes welding, painting, use of hazardous materials, or other activities that change
the atmosphere to be especially dangerous. The limited opening for entry and exit makes rescue difficult and
dangerous.
Most of the severe injuries and fatalities in confined spaces occur because an employee either went into a confined
space without first testing its atmosphere or did not continuously monitor the space. These are general guidelines for
all employees. Each Department that encounters confined spaces in their assigned duties will develop, train, operate
and monitor a specific confined space program for their area.
Some City employees may, during the course of their jobs, encounter confined spaces that have not been specifically
evaluated. Examples include firefighters and police officers during emergency response and inspectors, meter
readers or others during the normal course of their duties. More than half of the fatalities in confined spaces are
would-be rescuers. All employees who enter confined spaces must receive sufficient training to evaluate any
confined space and make responsible decisions. Prior to entry, assume that every confined space has an unknown
hazardous atmosphere.
A confined space is a space that has all of the following characteristics:
(1) is large enough for an employee to bodily enter and configured so that the employee can
perform assigned work, and
(2) has limited or restricted means for entry or exit, and
(3) Is not designed for continuous employee occupancy.
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Laurel, MT Safety Policy
Examples of confined spaces include: tanks, vessels, manholes, storm drains, headwalls, silos, storage bins,
hoppers, meter vaults, digesters, lift and transfer stations, shafts and pits. Unfavorable natural ventilation is common
in confined spaces.
The City of Laurel realizes that confined spaces present unique safety considerations and institute that;
• no one enters a hazardous confined space
• No city personnel shall enter into a manhole. If entry is necessary, a qualified contractor will be
employed to do such work
• work performed at any lift station will be with no less than 2 employees
• trenching performed at the cemetery will be with no less than 2 employees and shoring may be
necessary
• any entry into concealed spaces on vehicles such as garbage trucks or tank trucks will be with no less
than 2 employees
• at all confined space entry one employee will serve as the standby/rescue watch person
• no person shall remain in a confined space without a standby/rescue watch person in attendance
• access to confined spaces including crawl spaces under homes or manufactured homes will be
performed by no less than 2 employees
• all personal protective equipment will be worn during any confined space operation
• air monitoring devices will be calibrated by a certified entity once per month
• ladders shall be used in all trenches for access and egress
• lockout/Tag--out procedures will be instituted before entering a confined space
• In case of an emergency, 911 will be called before any rescue attempt is made
6.8 Personal Protective Clothing and Equipment
Personal protective clothing and equipment (PPE) plays an important role in protecting workers from hazards on the
job. PPE is required in particular locations and for certain tasks, based on safety regulations and good safety
practice. Examples of PPE include, but are not limited to:
• safety shoes
• fall protection harnesses
• protective headgear
• safety glasses
• goggles
• face shields
• welding glasses
• protective clothing
• high -visibility clothing
• hearing protection
• air purifying respirators
• self-contained breathing apparatus (SCBA)
• welding clothing
• gloves
• rubber boots
The City provides Personal Protective Equipment if PPE is required for certain tasks or in certain locations. Check
with your supervisor to learn what equipment is required and/or provided in your area. Departments will specify and
issue all required safety equipment to employees except in some cases where the PPE must be fitted to the
employee, such as safety shoes or prescription safety glasses. You must obtain department approval prior to the
purchase of safety shoes or glasses, and demonstrate that all safety specifications are met, in order to be reimbursed
for the cost.
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Laurel, MT Safety Policy
All PPE must meet the appropriate American National Standards Institute (ANSI) specifications as directed by
OSHA. Any employee who provides his or her own PPE must present the PPE to their supervisor for approval prior
to use on the job.
Even where specific PPE is not required, certain types of clothing may not be appropriate for some jobs or work
locations. For example, sandals, high -heeled shoes, and athletic -type shoes may not be suitable for some types of
jobs. Some non -PPE clothing and equipment may be provided by the department, but generally, it is the employee's
responsibility to be dressed properly for work.
Employee responsibilities:
1. Always use PPE when and where it is required.
2. Inspect PPE prior to each use.
3. Never use defective or damaged PPE.
4. Keep PPE in a clean and sanitary condition.
5. Follow the correct methods of putting on, taking off and adjusting PPE.
6. Properly care for, maintain and dispose of PPE.
6.9 Hearing Conservation/Protection
High noise levels damage your hearing and may also cause stress and fatigue. Hearing protection such as safety
earmuffs and earplugs are designed to reduce your exposure to harmful noise, while they enable you to hear
conversations and machine warnings. Never substitute audio headphones for hearing protection devices.
Always wear hearing protection in areas posted "HEARING PROTECTION REQUIRED" and follow department
rules for the use of hearing protection for designated operations or near particular equipment. In addition, follow the
three-foot rule — use hearing protection in situations where you must raise your voice to be heard by another person
at a distance of three feet.
Insert foam earplugs properly — roll the plug between your thumb and forefinger until it is completely compressed.
With the opposite hand pull the outer ear up and out and insert the plug into the ear, leaving a small portion of the
plug exposed.
If you are using earmuffs, be sure you have a good seal between the muff and the skin around your ear. Be sure that
your hair, jewelry, and glasses do not interfere with the seal. Earmuffs and earplugs may be worn together for added
protection.
6.10 Respiratory Protection
Respiratory protection is required for some employees as protection from exposure to high dust or particulate levels,
exposure to toxic materials or oxygen deficiency. If you are required to wear a respirator, you will be given a
medical examination, fit tested with the respirator and trained on the proper use and care of the respirator. In
addition, you will be required to be clean-shaven where the respirator facepiece contacts the skin.
In some situations, such as dusty outdoor conditions, dust masks will be available as a convenience. There is no
obligation that the masks be worn, and the requirements in the above paragraph do not apply.
6.11 Bloodborne Pathogens
Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV), which causes AIDS, are the two most
prominent bloodborne pathogens. Although these diseases are most commonly transmitted by sexual contact or
sharing infected hypodermic needles, occupational exposure usually occurs by:
• Accidental puncture with an infected needle
• Getting infected blood or other potentially infectious materials on your skin, especially if your skin has
open sores, nicks or cuts
• Getting infected blood or other potentially infectious materials in the mucous membranes of your eyes,
nose or mouth
In addition to blood, potentially infectious materials include semen, vaginal secretions and certain other body fluids
(cerebrospinal, etc.).
Many City employees, including law enforcement personnel, firefighters, solid waste workers, wastewater treatment
and individuals who perform janitorial functions, have the potential for bloodborne pathogen exposure. These
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Laurel, MT Safety Policy
employees shall be given initial training and offered HBV vaccinations at City expense (See HEPATITIS B
VACCINE DECLINATION Form on Page 20). Emergency services employees (Fire and Police) have the greatest
potential exposure and have extensive departmental procedures to cover potential exposure situations.
The following precautions are useful in avoiding exposure to bloodborne pathogens:
1. Do not eat, drink or use tobacco products around blood or other potentially infectious materials.
2. Do not perform janitorial, emergency rescue or other jobs where there is a risk of exposure to
bloodborne pathogens unless you have been trained to do so.
3. Follow department requirements concerning exposure to BBP, including the use of personal protective
equipment such as nitrite or other impervious gloves,
4. Minimize the risk of puncture by a discarded hypodermic needle:
• don't reach into trash containers or attempt to compact trash by pressing with hands or feet
• watch for needles in parks, restrooms, storm sewers, sanitary water system, police vehicles
and other places where they may be discarded
• don't pick up a needle with your bare hands — wear gloves or use tongs
5. Avoid direct contact with blood or other potentially infectious materials:
• use tongs or wear gloves to pick up condoms, sanitary napkins, and other items which may be
contaminated with body fluids
• use an approved disinfectant to destroy BBP virus before cleaning a potentially infected area
6. Clean up your own blood if possible after a minor injury; dispose of small quantities of cleanup
materials in a toilet.
7. Cover all wounds with waterproof bandages; replace the bandage as necessary.
8. Minimize contact with injured persons if you are not trained in emergency medical response.
9. Wash with soap and water immediately:
• after removing gloves and other personal protective equipment
• after exposure to potentially infectious materials
• after cleaning or decontamination of BBP
• after using the bathroom
• before eating
10. Report all exposure incidents to your supervisor and report to St. Vincent's Occupational Health for
evaluation and treatment.
11. Follow department procedures for dealing with potentially infectious materials.
6.12 Forklift Operations
Forklift operations require that the operator receive training from a qualified forklift mentor on the operation and
hazards associated with that machine. Examples of forklift safety practices include, but are not limited to:
• Only qualified and trained operators are to operate the forklift, no riders.
• do a daily pre-operation checklist and submit such documentation to the supervisor
• report all defects or accidents properly to a supervisor
• wear seat belts and appropriate personal protective equipment while operating the forklift
• make sure the pathway is wide enough to traverse and free of obstructions
• look all around before moving and in the direction of travel while moving
• Apply the parking brake before leaving the forklift. A forklift is considered unattended if the operator
is more than 25 feet from the forklift or not in direct visual contact with the forklift
• Sound the horn when approaching blind corners, exits, entrances or intersections.
6.13 Fall Protection
Fall protection is important in reducing the injuries and dangers associated with working from surfaces that are
elevated or sloped. Generally, the hazards associated with falls and the prevention techniques include but are not
limited to:
• Employees on an unguarded walking/working surface that is six (6) feet or more above a lower level
shall be protected from falling by the use of a fall protection system.
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Laurel, MT Safety Policy
• Fall protection shall be used when hazards such as moving equipment and electrical hazard are less
than six (6) feet below the walking/working level.
• Handrail/guardrail systems shall be 42-45 inches above the walking/working surface with mid -rails at
21 inches above the walking/working surface.
• Safety belts shall not be used as fall protection.
• Anchor points must be capable of supporting 5,000 pounds for each worker.
• Fall protection systems shall be rigged so that the maximum free fall is no greater than two (2) feet nor
contact any lower level or hazard.
• Tie off shall be at above the Dee -ring on the back of the worker's full body harness to avoid striking
lower levels.
• All personal fall protection/arrest systems shall be inspected prior to each use and if defective taken out
of service immediately.
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SECTION 7 DISCIPLINARY POLICY
The disciplinary policy will be enforced as outlined in the City Personnel Policy Manual and Collective Bargaining
Agreements.
SECTION 8 ACCIDENTANCIDENT REPORTING
WORKERS' COMPENSATION:
Employee occupational injuries and illnesses are covered by Workers' Compensation Insurance provided by the
Montana Municipal Insurance Authority. Workers' Compensation covers medical and rehabilitation expenses,
partial income replacement if the employee is out of work more than 4 days or 32 working hours, and benefits to the
surviving family in case of death. It is a no-fault system, providing exclusive remedy for on-the-job injuries or
illnesses regardless of blame, except in certain situations, such as employees:
■ Willfully hurting themselves;
■ Acting in a premeditated way to cause injury;
■ Starting a fight with a co-worker
■ Intentionally violating safety rules; and
■ Becoming intoxicated or impaired by drug use.
If you are injured on the job or have a work-related illness, report it to your supervisor immediately within 24 hours
by e-mail, text or verbally and get proper medical treatment. You may be denied benefits if you wait too long to
report an injury, because it may be difficult to establish the cause of the injury. Cooperate with the City, medical
professional, and insurance claims personnel in order to ensure that you receive your full Workers' Compensation
benefits.
Recovery from an occupational injury or illness is sometimes slow, but light duty or alternative duty is sometimes
possible during your transition back to normal employment. These transitional employment situations, and
sometimes rehabilitation programs recommended by medical professionals, can speed up your recovery and provide
you with better compensation than Workers Compensation alone.
Workers' Compensation income replacement does not begin until the occupational illness or injury has caused the
employee to miss work for 4 days (or 32 working hours), and provides only a portion of your normal wage.
Employees may elect to use vacation or sick leave credits in lieu of Workers' Compensation Payment.
REPORTING REQUIREMENTS
Report on-the-job injuries to your supervisor/employer within 24 hours by e-mail, text or verbally. You must
complete a Workers' Compensation Incident Report. We recommend that you report minor injuries to your
employer whether or not you receive medical treatment.
You must submit a written and signed Workers' Comp Incident Report within 72 hours from the date of the
accident. You can get this report from your supervisor. You will fill out the form and submit it to your supervisor
who will then forward the report to the Safety Officer so that it may be completed and filed with the insurance
company.
The City's Workers' Compensation carrier and claims processor is:
Montana Municipal Insurance Authority (MMIA)
PO Box 6669
Helena, MT 59604
406-443-0907
This is where physicians need to address their claims questions. Claim numbers will not be available for several
days following an injury. When the claim is received, by the insurance carrier, a number will be assigned to the
claim. A claim number is not required for a physician to file paperwork with MMIA. All they need to include
is the patient's name and date of injury.
Other Accident/Incident
Report all other vehicle accidents, City property damage and incidents of citizen injury and/or property damage to
your supervisor. You will need to fill out the Liability or Property Incident Report. You may attach pictures,
statements, sketches and other support data as appropriate. Report only factual information — do not speculate.
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City employees and officials have a duty to protect the City from unjust accusations and lawsuits. Do not admit
liability in any way. This is a matter for the police, the City Attorney, our insurance carrier and others to determine.
Do be careful what you say. If you say something like "We'll take care of it," you may mean that you'll turn in a
report, but the statement may be misconstrued to mean that the City is admitting fault. Do not admit guilt or
speculate about the cause of the accident; refer questions from citizens to the supervisor. Refer any questions about
the City's responsibilities or liabilities to your supervisor and/or the City Attorney.
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Laurel, MT Safety Policy
SECTION 9 TRAINING REQUIREMENTS FOR SAFETY & HEALTH
9.1 Required Training
The following training will be required for all employees:
1. Fire Prevention and Use of Fire Extinguishers
2. Emergency Action Plan (Evacuation)
3. Workplace Hazard Identification and Reporting
4. Accident and Incident Reporting
9.2 Available Training Programs
The Safety Officer, Department heads and /or supervisors will be responsible for providing additional opportunities
for safety training for all employees. Any Department requiring specific or general safety training should initially
contact the Safety Coordinator as a resource for obtaining such training.
Additional safety training may be necessary when a new safety program is established, employee job assignments
change, new substances, processes, procedures or equipment are introduced, or when a new hazard is identified.
SECTION 10 EMERGENCY EVACUATION & RESPONSE PLANS
Each Department within the City shall have posted in their work area a current Emergency Evacuation and Response
Plan, a copy of which shall be maintained in the Safety Officer's office.
This plan shall include maps and/or drawings indicating the safe egress from workplaces and buildings and a
procedure to be followed by employees in the event of specific emergency situations, such as fire or earthquake. As
part of each plan, there should be a designated safe gathering area for employees following such an evacuation,
which will allow for a proper accounting of employees.
Any revisions in the current plan must be submitted to the Safety Committee for review.
SECTION 11 SAFETY & HEALTH COMMUNICATION
Communication is the heart of an effective and successful Safety and Health Program. The Safety Officer shall be
considered the initial resource to aid Departments in offering continuing, regular, and current safety training. This
training may be accomplished through periodic safety meetings or various other formats.
The Safety Officer shall assist the Safety Committee in providing a system for employees to develop an awareness
and appreciation of safety through tools such as newsletters, periodic safety meetings, posters, and programs.
Additionally, the Safety Officer shall periodically review the effectiveness of these different formats and make
recommendations to the Safety Committee for improvements.
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Laurel, MT Safety Policy
SECTION 12 FORMS
HEPATITIS B VACCINE DECLINATION (MANDATORY)
I understand that due to my occupational exposure to blood or other potentially infectious materials I
may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with hepatitis B vaccine at no charge to myself. However, I decline hepatitis B vaccination
at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B,
a serious disease. If in the future I continue to have occupational exposure to blood or other potentially
infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination
series at no charge to me.
Name
Signature
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Laurel, MT Safety Policy
Department
Date
Date:
Employee Name:
Position: _
LJ New Hire
Department:
SAFETY ORIENTATION
❑Transfer ❑Rehire ❑Season LIOn-Call
Safety Policy and Responsibilities
Human Resources/Safety Officer
❑ Overview of Safety Policy
❑ Job Description — Safety Duties
❑ Evaluation — Attendance of Safety Meeting and Training
❑ Accident Reporting Procedures
❑ On -the job -accidents - First Report of Injury
- Incident Report
❑ Unsafe conditions or actions
❑ Near miss accidents
❑ Acknowledgment Receipt of Safety Policy in writing
Individual Department
❑ Introduction to supervisor
❑ Chain of command
❑ Tour facilities and equipment
❑ Location of first aid kits and equipment
❑ Emergency response to:
Natural disasters (flood/earthquake/etc.)
Fire response (types/techniques/exits/extinguisher/hoses
Bomb threats
Active Shooter
Location of Safety Equipment
❑ Personal Work Habits
❑ Acceptable Clothing & Footwear
❑ Housekeeping
❑ No Smoking Area
❑ General Operation and Maintenance of Equipment
❑ Potential on-the-job hazards
❑ Inform the employee of notices of posting (i.e., wage and hour, unemployment ins., workers'
compensation, FMLA, and EEOC).
❑ Procedures for reporting, investigating, and taking corrective action on all work-related
incidents, accidents, injuries, illnesses, and known unsafe work conditions or practices as
well as Liability for the City
❑ Job or Task -Specific Safety Training
❑ Review of SOP's for the Department
❑ Citizen Complaints
❑ Dealing with the Media
❑ Refresher Training
Signature of Employee: Date:
Signature of Supervisor:
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Date:
Incident Report and First Report of Injury and Occupational Disease Forms
Incident Reports and Worker's Compensation forms are available at City Hall from the
Safety Officer, City Treasurer or Clerk's office, once the form is completed return to the
Safety Officer for submittal.
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REPORT OF WORKPLACE HAZARD
Today's Date:
Name:
Description of Hazard:
Location of Hazard:
Has hazard been reported to supervisor? ❑ Yes ❑ No
If yes, who it was reported to and date reported:
PLEASE RETURN FORM TO THE SAFETY OFFICER OR IMMEDIATE
SUPERVISOR
SAFETY COMMITTEE USE
What has been done to correct the hazard?
Who took action to correct the hazard?
WORKERS' COMPENSATION INCIDENT
WORKER INFORMATION
*Claimant First Name:
Claimant Middle Name:
*Claimant Last Name:
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*Mailing Address:
Mailing Address 2:
*City:
*Primary Phone:
Phone 2:
E -Mail:
*State: *Postal Code:
❑ Home ❑ Mobile 0 Office ❑ Other:
❑ Home ❑ Mobile ❑ Office ❑ Other:
Education: ❑ Less than High School ❑ GED or High School Diploma ❑ Beyond High School
*Gender: 0 Male ❑ Female ❑ Unknown
*Marital Status: ❑ Married ❑ Separated 0 Single, Divorced 0 Unknown 0 Unmarried ❑ Widowed
Number of Dependents:
*Department:
Supervisor:
*Occupation:
WAGES
*Hire Date: Work Week: ❑ Sun ❑ Mon ❑ Tue ❑ Wed ❑ Thu ❑ Fri 0 Sat
Days Worked Per Week: Hours Worked Per Week:
*Worked Next Scheduled Shift? ❑ No ❑ Unknown ❑ Yes *Off Work More Than 4 Days? ❑ No ❑ Unknown 0 Yes
Date Last Worked: Date Returned to Work:
Employment Status: ❑ Full Time ❑ Other ❑ Part Time 0 Piece Worker ❑ Retired ❑ Seasonal 0 Volunteer
*Wage Rate: Wage Rate Type: ❑ Hourly 0 Daily ❑ Weekly ❑ Bi -Weekly ❑ Monthly
❑ Semi -Monthly 0 Annually
Extra Benefit Type: 0 Bonus ❑ Commissions 0 Other ❑ Overtime ❑ Room and Board Amount:
Full Pay on Day of Injury? ❑ Check if yes Salary Continued? ❑ Check if Yes *Payroll Classification Code:
Gross Earnings Pay Period 1: Gross Earnings Pay Period 2:
Gross Earnings Pay Period 3:
*Description of Accident:
*Injury/Illness: ❑ Illness ❑ Injury
*Part of Body:
*Date of Injury:
Laurel, MT Safety Policy
Gross Earnings Pay Period 4:
ACCIDENT DETAILS
*Cause of Injury:
*Nature of Injury:
Time of Injury:_
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Date of Death:
(1) Witness Full Name:
(2) Witness Full Name:
(3) Witness Full Name:
Accident on Employer's Premises?
*Date Reported to Member:
Accident Reported to:
Safety Equipment Provided?
❑ Yes ❑ No
Phone:
Phone:
Phone:
Date Reported to MMIA:
❑ Yes ❑ No Safety Equipment Used? ❑ Yes ❑ No
TREATMENT INFORMATION
Date of First Treatment:
*Initial Treatment: ❑ No Medical treatment ❑ Minor treatment on-site ❑ Minor Clinic/ Hospital
❑ Emergency Evaluation ❑ Hospitalization greater than 24 hours
❑ Future Major Medical/Lost Time Anticipated
Attending Physician: Hospital Name:
Address: Address:
City: City:
State: Postal Code: State: Postal Code:
Phone Number: Phone Number:
MEMBER/EMPLOYER INFORMATION
Member: City of Laurel
Mailing Address: PO Box 10
City: Laurel
State: Montana
Postal Code: 59044
*Prepared By:
*Prepared By Email:
Preparer Title:
Date Prepared:
Preparer Phone:
Is the Preparer the Primary Contact For Claim?
*Was Worker Injured While in Your Employ?
❑ Yes ❑ No
❑ Yes ❑ No
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Laurel, MT Safety Policy
*Is there a reason to question this accident? ❑ Yes ❑ No
*Entity Name:
Company Contact
First Name:
Middle Initial or Name:
Last Name:
Claimant:
*Mailing Address:
*City:
Laurel, MT Safety Policy
Liability or Property Incident
CLAIMANT (COMPANY)
CLAIMANT INFORMATION
*State: *Postal Code:
26
*Primary Phone:
Secondary Phone:
E -Mail:
*Event Date:
*Location:
*City:
*Date Reported to Member:
Reported By:
*Event Details:
(Please select all that apply)
WHAT CLAIM(S) ARE BEING REPORTED?
*State:
❑ Home ❑ Mobile ❑ Office ❑ Other:
❑ Home ❑ Mobile ❑ Office ❑ Other:
EVENT DETAILS
Event Time:
*Postal Code:
Time Reported to Member:
❑ Damaged/Injured Person (Not Workers Compensation) ❑ Member's Property ❑ Member's Vehicle(s)
❑ Other Party's Property ❑ Other Party's Vehicle(s)
Estimated Property Damage Amount:
ESTIMATED DAMAGE AMOUNTS
ADDITIONAL EVENT COMMENTS
Please enter any additional comments or information regarding the injury or damaged property (i.e. Driver contact
info, address info, etc.)
Name:
Address:
Laurel, MT Safety Policy
WITNESS INFORMATION
27
City:
Primary Phone:
Remarks:
Member: City of Laurel
FEIN: 81-6001283
Contact Phone: (406) 628-8791
Contact Person: Bethany Langve
Mailing Address: PO Box 10
City: Laurel
State: Montana
Postal Code: 59044
*Prepared By Email:
*Prepared By:
Preparer Title:
Date Prepared:
Preparer Phone:
Preparer Department:
Primary Departmental Contact Information
*Department Involved:
*Primary Contact for Claim:
*Primary Contact Title:
*Email:
*Primary Phone:
State: Postal Code:
Secondary Phone: _
MEMBER INFORMATION
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Laurel, MT Safety Policy
Liability or Property Incident
CLAIMANT (INDIVIDUAL)
*First Name:
Middle Initial or Name:
*Last Name:
CLAIMANT INFORMATION
Claimant:
*Mailing Address:
*City:
*Primary Phone:.
Secondary Phone:
E -Mail:
*Event Date:
*Location:
*State:
*City: *State:
*Date Reported to Member:
Reported By:
*Event Details:
*Postal Code:
❑ Home ❑ Mobile ❑ Office ❑ Other:
❑ Home ❑ Mobile ❑ Office ❑ Other:
EVENT DETAILS
Event Time:
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Laurel, MT Safety Policy
*Postal Code:
Time Reported to Member:
WHAT CLAIM(S) ARE BEING REPORTED?
(Please select all that apply)
❑ Damaged/Injured Person (Not Workers Compensation) ❑ Member's Property ❑ Member's Vehicle(s)
❑ Other Party's Property ❑ Other Party's Vehicle(s)
Estimated Property Damage Amount:
ESTIMATED DAMAGE AMOUNTS
ADDITIONAL EVENT COMMENTS
Please enter any additional comments or information regarding the injury or damaged property (i.e. Driver contact
info, address info, etc.)
Name:
Address:
City:
Primary Phone:
Remarks:
Member: City of Laurel
FEIN: 81-6001283
Contact Phone: (406) 628-8791
WITNESS INFORMATION
State:
Secondary Phone:
MEMBER INFORMATION
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Laurel, MT Safety Policy
Postal Code:
Contact Person:
Mailing Address:
City:
State:
Postal Code:
*Prepared By Email:
*Prepared By:
Preparer Title:
Bethany Langve
PO Box 10
Laurel
Montana
59044
Date Prepared:
Preparer Phone:
Preparer Department:
Primary Departmental Contact Information
*Department Involved:
*Primary Contact for Claim:
*Primary Contact Title:
*Email:
*Primary Phone:
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Laurel, MT Safety Policy