Subcontractor/Vendor Prequalification Questionnaire Completed Forms & Insurance Certificate To Be Submitted To:

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Junior Barber
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1 Jul-16 Subcontractor/Vendor Prequalification Questionnaire Completed Forms & Insurance Certificate To Be Submitted To: Company Name Divisions of Work/CSI Number(s) Address 1. City State Zip 2. Phone No. Fax 3. Website License No. Corporation Partnership Sole Proprietorship Union Affiliation Principals No. of Employees Regions of Work Metro Milwaukee Entire State of WI Years in Business Special Designations/Certifications (i.e., DBE, WBE, EBE, etc.) Racine/Kenosha Other Person who should receive Invitation to Bid Bank Reference Bonding Information Name Title Name Contact Person Phone No. Name Contact Person Phone No. Bonding Capacity $ Workers Compensation EMR (Experience Modification Rate) Safety Program Contact Name Phone No. Insurance Information (Attach copy of Certificate(s). Berghammer's insurance requirements are attached.) Agent Name Address Phone No. Billing/Lien Waiver Contact Name Phone No. Administration Contact Name Phone No. Project References: 1. Project Name Location Contact Name & Company Phone No. Date Completed Contract Amount 2. Project Name Location Contact Name & Company Phone No. Date Completed Contract Amount W:\Templates and Forms\Project Management\Subcontractor PREQUALIFICATION

2 Rev. 11/2017 BERGHAMMER CONSTRUCTION CORPORATION INSURANCE REQUIREMENTS Project: Subcontractor shall obtain insurance with limits at least equal to those specified below. TYPE OF INSURANCE LIMITS OF LIABILITY COMMERCIAL GENERAL LIABILITY Occurrence Form Bodily Injury/Property Damage (CSL) Comprehensive Form Each Occurrence $1,000,000 Premises/Operations General Aggregate $2,000,000 Products/Completed Operations Products Comp/OPS Aggregate $1,000,000 Contractual Liability Personal & Advertising Injury $1,000,000 Independent Contractors Personal Injury Explosion/Collapse/Underground (XCU) General Aggregate applies on a per project basis AUTOMOBILE Any Automobile Bodily Injury (Per Person) $1,000,000 All Owned Automobiles Bodily Injury (Per Accident) $1,000,000 Hired Automobiles Property Damage $1,000,000 Non-Owned Automobile or Bodily Injury/Property Damage (CSL) $1,000,000 UMBRELLA LIABILITY Each Occurrence $2,000,000 Coverage shall be over Commercial GL, Auto & Aggregate $2,000,000 Employers Liability policies on a following form basis WORKERS COMPENSATION AND Coverage A Statutory EMPLOYERS LIABILITY Coverage B (Must Extend To Every Employee, Each Accident $100,000 Including Owners) Disease - Policy Limit $500,000 Disease Each Employee $100,000 PROFESSIONAL LIABILITY (Errors & Omissions) Claims Made $1,000,000 (Required Only if Subcontract is Awarded on a Design/Build Basis) Berghammer Corporation, the Owner and others as required in the Contract Documents shall be named as ADDITIONAL INSUREDS on the General Liability and Automobile Liability Policies on a primary and non-contributory basis. A Waiver of Subrogation in favor of the above Additional Insureds shall be included in the General Liability and workers compensation policies. The Additional Insured endorsement must be ISO form CG 2010 (07 04 edition) and CG 2037 (07 04 edition) or its equivalent and provide Products/Completed Operations coverage. Products/Completed Operations coverage shall remain in effect for at least three (3) years from the date of acceptance of the project. It is understood and agreed that the insurance coverages and limits, required above, shall not limit the extent of the Subcontractor s responsibilities and liabilities specified within the Contract Documents or by law. Limits of liability beyond those required above by Contractor, or any type of insurance not described above which any Subcontractor normally requires for its own protection, or which Subcontractor is required by law to carry, shall be Subcontractor s responsibility and at Subcontractor s own expense. The policies obtained and maintained to provide the specified insurance must provide that the required coverage and limits will not be altered, cancelled or allowed to expire without at least 30 days prior written notice to CONTRACTOR. Before beginning any work under this subcontract, SUBCONTRACTOR and SUB-SUBCONTRACTORS will provide to CONTRACTOR insurance certificates showing compliance with these insurance specifications. Requirements subject to change based on Owner requirements.

VENDOR PREQUALIFICATION FORM

VENDOR PREQUALIFICATION FORM Date: Please complete this form and return to Rockford Construction via e mail (prequal@rockfordconstruction.com) or fax (1 616 285 6980 must include the 1 616). ALL AREAS