SUBCONTRACTOR PRE-QUALIFICATION STATEMENT

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1 SUBCONTRCTOR PRE-QULIFICTION STTEMENT GENERL INFORMTION ND CORPORTE HISTOR Legal Name Of Business Office Physical ddress Mailing ddress City State Zip Code Web ddress Primary Contact Name Estimating Contact Name ccounting Contact Name Fax Corporation Partnership Individual Sole Proprietorship Joint Venture Other If Incorporated, State Of Incorporation Federal ID# ears In Business Under Current Name Date Company Began Under Present Name Have you done business under a different name? If so, what was that name? Stock Holders Equity verage Number of Staff Employed By Firm: Office Field Total Last ear Previous ear FINNCIL CRITERI-nnual Sales for Last Three ears Page 1 of 7 For Internal Use Only: Estimating /P Supplier Subcontractor ll Regions Specific Regions

2 SFET SUBCONTRCTOR PRE-QULIFICTION STTEMENT Last Three ears EMR Rating: 20 EMR 20 EMR 20 EMR Last ear s total number of OSH Recordable Injury and Illness Types from OSH 300 Log Total hours worked by all employees last year Number of Cases Total number of deaths **** Total number of cases with days away from work Total number of cases with job transfer or restriction Total number of other recordable cases Number of Days Total number of days of job transfer or restriction Total number of days away from work Standard Industrial Classification (SIC), if known (e.g., SIC 3715) Does your firm have a written Safety Program? es No If yes, is a copy available? es No Does your firm have a safety officer/department? es No If yes, provide name and title Does your firm hold weekly 5-minute safety talks? es No Does your firm provide foreman safety training? es No If yes, at what frequency is the training? Does your firm conduct safety inspections? es No If yes, how often is this inspection conducted? If yes, who conducts this inspection (provide name and title)? Does your firm give orientation/safety instruction to new hires? es No In the past three years, has your firm been cited by State of Federal OSH for any willful violations? **** es No **** If yes, please list on a separate sheet the details of all such violations and submit it with this form. EXPERIENCE List three (3) most significant projects presently under construction Project Name General Contractor rchitect Contract mount ward Date List three (3) most significant projects completed in the last five (5) years Project Name General Contractor rchitect Contract mount ward Date List three (3) significant references that we may contact. Name ddress City State/Zip REQUIRED DOCUMENTTION: Letter from agent or actual Certificate of Liability Insurance, which provides current coverage and limits. letter from your insurance carrier or State Fund verifying Experience Modification Rating. Billable hourly rates if subcontractor is interested in engaging in a Master Subcontract greement. The MS will enable the contractor to perform time and material work without resubmitting information for each job. OSH 300 and 300 Logs for the last twelve months Written Safety Manual Completed IRS Form W-9 Reviewed Subcontract Template I hereby certify that the answers to the foregoing questions and all documents contained herein are true and correct Signature Date Name Typed Or Printed of uthorized Representative Page 2 of 7

3 SUBCONTRCTOR PRE-QULIFICTION STTEMENT Please indicate all trade divisions which your company performs (check all that apply): Page 3 of 7

4 CLIMS-MDE GEN'L GGREGTE LIMIT PPLIES PER: PRO- POLIC JECT LOC UTOMOBILE LIBILIT N UTO LL OWNED HIRED UMBRELL LIB EXCESS LIB CERTIFICTE OF LIBILIT INSURNCE SCHEDULED NON-OWNED CLIMS-MDE DED RETENTION WORKERS COMPENSTION ND EMPLOERS' LIBILIT / N N PROPRIETOR/PRTNER/EXECUTIVE OFFICE/MEMBER EXCLUDED? N / (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERTIONS below MED EXP (ny one person) PERSONL & DV INJUR GENERL GGREGTE PRODUCTS - COMP/OP GG COMBINED SINGLE LIMIT (Ea accident) BODIL INJUR (Per person) BODIL INJUR (Per accident) PROPERT DMGE (Per accident) ECH RENCE GGREGTE WC STTU- TOR LIMITS E.L. ECH CCIDENT OTH- ER E.L. DISESE - E EMPLOEE E.L. DISESE - POLIC LIMIT DTE (MM/DD/) THIS CERTIFICTE IS ISSUED S MTTER OF INFORMTION ONL ND CONFERS NO RIGHTS UPON THE CERTIFICTE HOLDER. THIS CERTIFICTE DOES NOT FFIRMTIVEL OR NEGTIVEL MEND, EXTEND OR LTER THE COVERGE FFORDED B THE POLICIES BELOW. THIS CERTIFICTE OF INSURNCE DOES NOT CONSTITUTE CONTRCT BETWEEN THE ISSUING INSURER(S), UTHORIZED REPRESENTTIVE OR PRODUCER, ND THE CERTIFICTE HOLDER. IMPORTNT: If the certificate holder is an DDITIONL INSURED, the policy(ies) must be endorsed. If SUBROGTION IS WIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTCT NME: gent's Name PHONE FX our Insurance Company Name (/C, No, Ext): xxx-xxx-xxxxx (/C, No): xxx-xxx-xxxx E-MIL name@xxxxxxxxxx.xxx ddress DDRESS: INSURER(S) FFORDING COVERGE NIC # Insurance Company 1 PRODUCER INSURED INSURER : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : Insurance Company 2 COVERGES CERTIFICTE NUMBER: REVISION NUMBER: B C D our Company name / DB Name (must match W9) ddress THIS IS TO CERTIF THT THE POLICIES OF INSURNCE LISTED BELOW HVE BEEN ISSUED TO THE INSURED NMED BOVE FOR THE POLIC PERIOD INDICTED. NOTWITHSTNDING N REQUIREMENT, TERM OR CONDITION OF N CONTRCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICTE M BE ISSUED OR M PERTIN, THE INSURNCE FFORDED B THE POLICIES DESCRIBED HEREIN IS SUBJECT TO LL THE TERMS, EXCLUSIONS ND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN M HVE BEEN REDUCED B PID CLIMS. INSR DDL SUBR POLIC EFF POLIC EXP LTR TPE OF INSURNCE INSR WVD POLIC NUMBER (MM/DD/) (MM/DD/) LIMITS GENERL LIBILIT ECH RENCE Start Dates End Dates DMGE TO RENTED COMMERCIL GENERL LIBILIT PREMISES (Ea occurrence) Other (if applicable) Insurance Company 3 Insurance Company 4 100, , , DESCRIPTION OF OPERTIONS / LOCTIONS / VEHICLES (ttach CORD 101, dditional Remarks Schedule, if more space is required) RE: ny project: The following applies when required by contract a.j. Veneklasen, Inc., the owner; rchitect/engineer; and all other parties as required by contract, are named as dditional Insured on a primary and non-contributory basis. General Liability aggregate applies per project, additional insured endorsement will provide Ongoing & Completed Operations Coverage. The insurance companies above waive their rights of subrogation on the general liability and worker's compensation policies. CERTIFICTE HOLDER a.j. Veneklasen, Inc Kendrick St SE Grand Rapids, MI CNCELLTION SHOULD N OF THE BOVE DESCRIBED POLICIES BE CNCELLED BEFORE THE EXPIRTION DTE THEREOF, NOTICE WILL BE DELIVERED IN CCORDNCE WITH THE POLIC PROVISIONS. UTHORIZED REPRESENTTIVE CORD 25 (2010/05) gent's Signature CORD CORPORTION. ll rights reserved. The CORD name and logo are registered marks of CORD Clear ll

5 CLIMS-MDE GEN'L GGREGTE LIMIT PPLIES PER: PRO- POLIC JECT LOC UTOMOBILE LIBILIT N UTO LL OWNED HIRED UMBRELL LIB EXCESS LIB CERTIFICTE OF LIBILIT INSURNCE SCHEDULED NON-OWNED CLIMS-MDE DED RETENTION WORKERS COMPENSTION ND EMPLOERS' LIBILIT / N N PROPRIETOR/PRTNER/EXECUTIVE OFFICE/MEMBER EXCLUDED? N / (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERTIONS below DESCRIPTION OF OPERTIONS / LOCTIONS / VEHICLES (ttach CORD 101, dditional Remarks Schedule, if more space is required) MED EXP (ny one person) PERSONL & DV INJUR GENERL GGREGTE PRODUCTS - COMP/OP GG COMBINED SINGLE LIMIT (Ea accident) BODIL INJUR (Per person) BODIL INJUR (Per accident) PROPERT DMGE (Per accident) ECH RENCE GGREGTE WC STTU- TOR LIMITS E.L. ECH CCIDENT OTH- ER E.L. DISESE - E EMPLOEE E.L. DISESE - POLIC LIMIT DTE (MM/DD/) THIS CERTIFICTE IS ISSUED S MTTER OF INFORMTION ONL ND CONFERS NO RIGHTS UPON THE CERTIFICTE HOLDER. THIS CERTIFICTE DOES NOT FFIRMTIVEL OR NEGTIVEL MEND, EXTEND OR LTER THE COVERGE FFORDED B THE POLICIES BELOW. THIS CERTIFICTE OF INSURNCE DOES NOT CONSTITUTE CONTRCT BETWEEN THE ISSUING INSURER(S), UTHORIZED REPRESENTTIVE OR PRODUCER, ND THE CERTIFICTE HOLDER. IMPORTNT: If the certificate holder is an DDITIONL INSURED, the policy(ies) must be endorsed. If SUBROGTION IS WIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTCT gent's Name PRODUCER our Insurance Company Name ddress INSURED NME: PHONE (/C, No, Ext): E-MIL DDRESS: INSURER : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : xxx-xxx-xxxxx name@xxxxxxxxxx.xxx INSURER(S) FFORDING COVERGE Insurance Company 1 Insurance Company 2 COVERGES CERTIFICTE NUMBER: REVISION NUMBER: B C D our Company name / DB Name (must match W9) ddress FX (/C, No): xxx-xxx-xxxx THIS IS TO CERTIF THT THE POLICIES OF INSURNCE LISTED BELOW HVE BEEN ISSUED TO THE INSURED NMED BOVE FOR THE POLIC PERIOD INDICTED. NOTWITHSTNDING N REQUIREMENT, TERM OR CONDITION OF N CONTRCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICTE M BE ISSUED OR M PERTIN, THE INSURNCE FFORDED B THE POLICIES DESCRIBED HEREIN IS SUBJECT TO LL THE TERMS, EXCLUSIONS ND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN M HVE BEEN REDUCED B PID CLIMS. INSR DDL SUBR POLIC EFF POLIC EXP LTR TPE OF INSURNCE INSR WVD POLIC NUMBER (MM/DD/) (MM/DD/) LIMITS GENERL LIBILIT ECH RENCE Start Dates End Dates DMGE TO RENTED COMMERCIL GENERL LIBILIT PREMISES (Ea occurrence) x Other (if applicable) Insurance Company 3 Insurance Company 4 RE: ny project: The following applies when required by contract a.j. Veneklasen, Inc., the owner; rchitect/engineer; and all other parties as required by contract, are named as dditional Insured on a primary and non-contributory basis. General Liability aggregate applies per project, additional insured endorsement will provide Ongoing & Completed Operations Coverage. The insurance companies above waive their rights of subrogation on all policies. NIC # 100, , Professional Liability CERTIFICTE HOLDER a.j. Veneklasen, Inc Kendrick St SE Grand Rapids, MI CNCELLTION SHOULD N OF THE BOVE DESCRIBED POLICIES BE CNCELLED BEFORE THE EXPIRTION DTE THEREOF, NOTICE WILL BE DELIVERED IN CCORDNCE WITH THE POLIC PROVISIONS. UTHORIZED REPRESENTTIVE CORD 25 (2010/05) gent's Signature CORD CORPORTION. ll rights reserved. The CORD name and logo are registered marks of CORD Clear ll

EVIDENCE OF PROPERTY INSURANCE

EVIDENCE OF PROPERTY INSURANCE THIS EVIDENCE OF PROPERTY INSURNCE IS ISSUED S MTTER OF INFORMTION ONLY ND CONFERS NO RIGHTS UPON THE DDITIONL INTEREST NMED BELOW. THIS EVIDENCE DOES NOT FFIRMTIVELY OR NEGTIVELY MEND, ETEND OR LTER THE