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This is to certify that I have received a copy of THE COMPANY Code of Safe Practices.

I have read these instructions, understand them, and will comply with them while
working for the company.

I understand that failure to abide by these rules may result in disciplinary action and
possible termination of my employment with this COMPANY.

I also understand that I am to report any injury to my foreman or superintendent
immediately and report all safety hazards.

I further understand that I have the following “Safety” rights:

ˆ I am not required to work in any area I feel is not safe.

ˆ I am entitled to information on any hazardous material or chemical I am
exposed to while working.

ˆ I am entitled to see a copy of THE COMPANY Safety and Health Manual.

ˆ I will not be discriminated against for reporting safety concerns.

_______________________________________________________________________
Employee Name Signature Date

_______________________________________________________________________
Supervisor Name Signature Date

cc: Employee
File

Premium Cost Containment Form A Loss Prevention & Loss Control ©SAFETY SERVICES COMPANY