SUBCONTRACTOR QUALIFICATION STATEMENT

Transcription

1 SUBCONTRACTOR QUALIFICATION STATEMENT The information included herein shall not be disclosed outside SEDALCO and will not be duplicated, used or disclosed - in whole or in part for any purpose other than to serve as an element for consideration in award of contract. Name of Firm: ( ) Corporation ( ) Partnership ( ) Proprietorship Address: Telephone: Fax: How long has your company been in business under this name? year(s) Parent Company: Owners and/or Partners Name Percentage of Ownership % % % % Affiliates, Divisions & Subsidiaries (add sheets as required) Name: Address: Telephone: Fax: Name: Address: Telephone: Fax:

2 FOR CORPORATION ONLY Date of Incorporation Name of State(s) in which incorporated If not incorporated in Texas: Give Certificate of Authority to do business in Texas. Certificate No. & Date: President s Name Secretary s Name Vice President s Name Treasurer s Name FOR PARTNERSHIP ONLY Is the Partnership: Date of Organization General Limited Association Names and addresses of all partners (include zip codes): (Use additional sheet if necessary.) 1) 2) 3) FINANCIAL CONDITION Dunn & Bradstreet Rating and ID Code: Maximum Bonding Capacity: Individual Project Bonding Company (Name and Address): Phone: Fax: Aggregate Bonding Company (Name and Address): Phone: Fax:

3 Attach statement of Financial Condition, including Contractor s latest regular dated financial statement or balance sheet which must contain the following items: CURRENT ASSETS: (Cash, joint venture accounts, accounts receivable, accrued interest on notes, deposits and materials and prepaid expenses), net fixed assets and other assets. CURRENT LIABILITIES: (Accounts payable, notes payable, accrued interest on notes, provision for income taxes, advances received from owners, accrued salaries, accrued payroll taxes), other liabilities and capital, (capital stock, authorized and outstanding shares par values, earned surplus). Date of Statement or Balance Sheet Name & Address with Zip Code Bank Reference: Finance/Credit References: Institution Name: Address: Name of Contact: Telephone No.: Fax No.: Institution Name: Address: Name of Contact: Telephone No.: Fax No.: Institution Name: Address: Name of Contact: Telephone No.: Fax No.: Attach a copy of your current Certificate of Insurance indicating your standard coverage on General Liability, Automobile Liability, Excess Liability and Worker s Compensation.

4 GENERAL CONTRACTOR REFERENCES (Contracted with in the Past Three (3) Years) General Contractor Project $ Amount Contact Phone What is the largest contract you have completed? U.S. $ Year Business Volume Average annual billable volume during the past five years U.S. $ Estimated billable volume this year: Estimated volume carryover next year: U.S. $ U.S. $ Contract Values Preferred Contract Value: 50, (and under) 50, , , , , , , ,000, ,000, ,000, ,000, ,000, Maximum contract value that can be handled effectively: U.S. $ over months. GENERAL INFORMATION Percent of Work Done by Own Employees: % No. of Years in business: If you have done business under a different name, please give name and address.

5 Has firm ever failed to complete a project or defaulted on a contract? If so, state where and why: Has firm ever been engaged in litigation over any contract? If so, state where and why. A. MAJOR MATERIAL SUPPLIERS TO BE USED ON THIS PROJECT: 1) Supplier s Name: Material to be Purchased 2) Supplier s Name: Material to be Purchased 3) Supplier s Name: Material to be Purchased B. LOWER TIER SUBCONTRACTORS THAT WILL BE USED ON THIS PROJECT: 1) Subcontractor s Name Work to be Performed 2) Subcontractor s Name Work to be Performed

6 3) Subcontractor s Name Work to be Performed 4) Subcontractor s Name Work to be Performed (attach additional sheets if necessary) C. Will your employees be on your direct company payroll or will they be furnished to you though a labor service contractor? If you use a labor service contractor, please furnish the following information: Name of Labor Service Contractor: Contact Person: Address: Telephone No.: Fax No. (Labor Service will be required to maintain contractual insurance.) Total Permanent Employees: PERSONNEL Craftsmen Supervision/Admin Laborers Highest manpower level in past three years: Lowest manpower level in past three years:

7 Proposed organization for the execution of the work; listing all personnel committed to participate in the execution of the work, including their previous experience and positions held in previous jobs. (Attach resumes.) Proposed Project Manager Proposed Project Superintendent Other Name Present Position or Office Years of Experience Typical Amount Type of Work Responsibility EQUIPMENT List the major equipment, types and quantity proposed for the execution of the work. Identify as owned or leased. OTHER List any specific ideas concerns, comments or statements concerning this project, which may influence our decision to award this work to your firm. LONG LEAD ITEMS List any items that cannot be procured within 3 weeks or less.

8 CURRENT COMPLETED PROJECTS List the major construction contracts your company has under contract or completed over the past 5 years on the attached sheets. Performance SAFETY 1) What is your company s Interstate Worker s Compensation Experience Modification Rate (EMR) for the last four years? In addition, please provide your EMR rate for the previous four years on your insurance underwriter s letterhead. 2) Do you complete an OSHA 300 Log on a regular basis? Safety Programs and Policies 3) Do you have a written safety, health and environmental program or manual for your company? If yes, please provide us with a copy. 4) Does your policy include a graduated system of enforcement for non-compliance (for example, progressive discipline) with safety and health requirements? If yes, please describe your system on a separate sheet. 5) Do you have a written hazard communication program? If yes, please provide us with a copy. 6) Do you maintain an on-site MSDS file with an index for hazardous chemicals? 7) Do you have a substance abuse policy? 8) Do you have a safety orientation program for new employees? If yes, what does it include? 9) Do you prequalify your subcontractors based on their safety performance? 10) Do you have any safety training programs for your employees? If yes, please describe the programs. 11) Do you take any precautions to provide first aid or other medical services if one of your employees is injured on the jobsite? If yes, please describe.

9 Safety and Oversight 12) Do you have a full time safety director? 13) Do you appoint one of your employees as an on-site safety coordinator? Yes No 14) Do you provide safety meeting topics for on-site safety coordinators? Yes No If yes, state the frequency. 15) Do you hold on-site safety or tool box meetings for your employees and your subsubcontractors employees? 16) Do you have Spanish speaking employees working for you? 17) Do you provide bilingual safety training for your Spanish speaking employees? 18) Do you lease your employees from a leasing company? Inspections 19) Do you conduct job site safety inspections of general working conditions? If yes, describe who conducts them, how often, and if a written report is kept. 20) Do you conduct equipment inspections that comply with applicable government requirements? If yes, describe who conducts them, how often, and if a written report is kept. Training Programs (SEDALCO believes in training. Subcontractors with documented training plans in place are preferred in Subcontractor selection process.) 1) Does your firm have a published training program? Yes No 2) If yes, describe how training is performed.

10 3) How is training financed? Signature: Dated this day of,. Company Name: By: Title: Mr./Ms. hereby being duly sworn deposes and says that the information provided herein is true and sufficiently complete so as not to be misleading. Subscribed and sworn before me this day of,. SEAL NOTARY PUBLIC TYPE OR PRINT NAME My Commission Expires: SEDALCO ISSUE DATE: AUG 2008(rev )

11 CURRENT PROJECTS List the major construction projects your organization has underway on this date: PROJECT OWNER PHONE NO. GENERAL CONTRACTOR PHONE NO. CONTRACT AMOUNT PERCENT COMPLETE SCHEDULED COMPLETION

12 PROJECTS COMPLETED WITHIN THE LAST THREE (3) YEARS List the major construction projects your organization has completed within the past three (3) years: PROJECT OWNER PHONE NO. GENERAL CONTRACTOR PHONE NO. CONTRACT AMOUNT PERCENT COMPLETE SCHEDULED COMPLETION