General Safety Affidavit Form

GENERAL SAFETY AFFIDAVIT FORM

Affiant Name:     Company Name:

Company Address:

Position/Title of Affiant:     Affidavit Date:

RECITALS

WHEREAS, Affiant is employed by or acting on behalf of Company Name and has personal knowledge of the safety practices, training, and site conditions described herein; and

WHEREAS, Affiant has been requested to provide a sworn statement confirming the existence, condition, and compliance status of safety measures at the work site identified in this affidavit; and

WHEREAS, this affidavit is provided to induce reliance by the Company, its contractors, clients, insurers and regulators on the representations and certifications set forth below.

NOW THEREFORE

Affiant, being duly sworn, certifies, represents and affirms under penalty of perjury as follows:

1. DEFINITIONS

For purposes of this affidavit, the following terms have the meanings set forth below: "Safety Program" means the site-specific written procedures, training, inspection and hazard control measures implemented at the work site; "Affiant" means the person identified above who makes this affidavit.

2. STATEMENT OF FACTS AND REPRESENTATIONS

2.1 Affiant affirms that the information supplied in this affidavit is true and correct to the best of Affiant's knowledge and belief.

2.2 Work Site Location:

2.3 Affiant represents that the Safety Program applicable to the work site includes, at a minimum, written procedures addressing hazard identification, personal protective equipment, emergency response, equipment maintenance, and employee training.

3. SAFETY PROCEDURES, TRAINING AND INSPECTIONS

3.1 Affiant certifies that all employees and contractors performing work at the work site have received initial safety orientation covering site hazards and required controls within: of assignment.

3.2 The following safety measures have been implemented at the work site (check all that apply) and are current as of the affidavit date:

PPE Provided and routinely inspected

Written hazard communication program in place

Regular equipment inspection and maintenance program

Permit-required procedures for confined spaces, hot work, and similar hazards

3.3 Affiant shall list any additional site-specific controls, special permits or limitations below:

4. TRAINING, QUALIFICATIONS AND RECORDS

4.1 Affiant certifies that training records, inspection logs, and equipment maintenance records supporting the representations in this affidavit are maintained at:

4.2 Most recent employee safety training completion date:

5. INCIDENTS, REPORTING AND CORRECTIVE ACTION

5.1 Affiant certifies that, to Affiant's knowledge, there have been reportable incidents at the work site in the prior 12 months. If any, provide brief descriptions and corrective actions taken below.

5.2 Affiant agrees to notify Company promptly of any subsequent incident, hazard discovery, or material change in site conditions that would affect the accuracy of this affidavit.

6. INDEMNITY AND LIABILITY

6.1 Affiant acknowledges that the representations made herein may be relied upon by Company and its contractors. Affiant agrees to indemnify, defend and hold harmless Company from any claims, losses or liabilities arising from Affiant's knowing misrepresentation or material omission in this affidavit.

7. COMPLIANCE AND INSPECTIONS

7.1 Affiant consents to reasonable inspections by Company or its designated agents to verify the factual statements contained in this affidavit. Such inspections shall be conducted during normal business hours upon reasonable notice unless an imminent hazard requires immediate access.

8. NOTICES

All notices required or permitted under this affidavit shall be in writing and delivered to the mailing addresses set forth below. Notice is effective upon delivery or three business days after deposit in the U.S. mail, postage prepaid, addressed as follows:

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

9.1 Governing Law. This affidavit shall be governed by and construed in accordance with the laws of the jurisdiction specified by Company Name where the work site is located, without regard to its conflict of law principles.

9.2 Entire Agreement. This affidavit, together with any documents expressly incorporated herein by reference, constitutes the entire agreement between Affiant and Company with respect to the matters contained herein and supersedes all prior understandings.

9.3 Severability. If any provision of this affidavit is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. AMENDMENTS; WAIVER; COUNTERPARTS

10.1 Amendments. No amendment or modification of this affidavit will be effective unless reduced to writing and signed by both Affiant and an authorized representative of Company.

10.2 Waiver. The waiver by either party of a breach of any provision of this affidavit will not operate or be construed as a waiver of any subsequent breach.

10.3 Counterparts. This affidavit may be executed in counterparts, each of which will be deemed an original and all of which together will constitute one instrument.

11. VERIFICATION AND OATH

Affiant affirms under penalty of perjury under the laws of the applicable jurisdiction that the statements contained in this affidavit are true and correct to the best of Affiant's knowledge, information, and belief.

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