The Hilgeman Group, Inc.

General Company Information

Company Name:

Your Email Address:

Mailing Address:

City:

State:

Zip Code:

Physical Address:

City:

State:

Zip Code:

Number of Facilities at the Location:

Number of Production Employees:

Is this a Unionized Company?

yes no

If YES, Name of Union:

Number of Production Shifts per Day:

3 2 1

Facility Size: (square footage)

Key Contact Information

Main Safety contact at this facility

Name:			Telephone:
Title:			Email Address:

Main Engineering contact at this facility

Name:			Telephone:
Title:			Email Address:

Main Maintenance contact at this facility

Name:			Telephone:
Title:			Email Address:

Facility Electrical Information

Name of Electric Utility Supplier:
Does Your Facility Have Electrical Drawings?:	yes no
If, YES When Were These Drawings Last Updated?	(estimate year)

Please Estimate the Number of Each of The Following (Rough Estimate):

Machines:

Transformers:

Bussplugs:

Motor Control Centers:

Panelboards:

Switchboards:

Size of Main Transformer:

Maximum Voltage Inside the Facility:

Maximum Amps Inside the Facility:

Qualified Electrical Employees

Number of Employees Who Are Authorized to Conduct Live Electrical Work (including Troubleshooting, Maintenance, Engineering, Etc.):

OSHA/NFPA Arc Flash & Electrical Safety History

Has Your Company Experienced an Employee Fatality due to an Arc Flash?
Has Your Company Experienced an Employee Injury due to an Arc Flash?
Has Your Company Experienced an Employee Fatality due to Electrocution?
Has Your Company Experienced an Employee Injury due to Electrical Exposure?
Has an Arc Flash or Arc Blast Event Ever Happened at Your Company?
If yes, Please Indicate Where The Event Occurred: (at a Disconnect, Bussplug, MCC, Other)
Is Your Company Currently Negotiating an Agreed Settlement for Compliance Violations with OSHA?
Approximate Date of Most Recent Comprehensive OSHA Compliance Inspection: (dd/mm/yyyy)