SUBCONTRACTOR Pre-Qualification Form

Transcription

1 Please complete the form below and (form and all attachments) to Jodi Huntoon at or fax to If all information is not provided and all attachments are not submitted this will significantly delay approval or your pre-qualification could be rejected. Please note that this is a preliminary pre-qualification form and includes only our minimum requirements. Additional information may be requested by the job owner or due to the type of work to be performed. DATE COMPLETED: Has your company submitted a bid within the last 30 days? COMPANY INFORMATION Company s Legal Name: Address: Phone: Website: Estimating Contact: Title: Address: Year Company Founded: Type of Company: C Corporation S Corporation Partnership Are there any affiliated subsidiaries? If yes, name them: Is your firm owned or controlled by another organization? If yes, name them: Corporation Federal Employer s Tax ID#: Partnership/Individual Social security number (if no tax ID is available): State Unemployment Insurance #: Union: Total Number of Current Employees: How many Employees? Sole Proprietor LLC Other Office Personnel Average Field Labor Field Supervisors Minority Business Enterprise Status:

2 Preferred Project Size: $10K-$100K $100K-$250K $251K-$500K $1M + List the Geographical areas in which you work: List the trades you normally perform with your own forces: What % of the Company s work is normally subcontracted? CONTRACTOR S LICENSE(S): STATES and LOCAL (Attach Copy) State: License Number: License Holder: State: License Number: License Holder: Local: License Number: License Holder: Local: License Number: License Holder: COMPANY S PRINCIPALS Name: Title: Home Address: Phone: Name: Title: Home Address: Phone: Name: Title: Home Address: Phone: Name: Title: Home Address: Phone: Name: Title: Home Address: Phone: Name: Title: Home Address: Phone:

3 Current Surety Company: Broker Agent: Telephone: Bond Rates: (Please enter bond rates for..) Single Project Bonding Capacity: $ Aggregate Bonding Capacity: $ Company Safety Professional: Title: Telephone: Total # of Full Time Employees Total # of Part Time Employees Volume: $100,000 $500,000 $1M $2M $5M SURETY INFORMATION Bond % Rate: SAFETY INFORMATION OSHA 300 INFORMATION A. OSHA Recordable Incident Rates B. Lost Time Incident Rate C. Number of Recordable Injury Cases D. Number of Lost Time Incidents/Illnesses E. Number of Days away from work F. Number of Fatalities G. Total Employee Hours Worked *Note for A. and B. use the formula: Incidents multiplied by 200,000 then divided by # of employee hours worked. EXPERIENCE MODIFICATION RATE (EMR) List corporate Worker s Compensation Experience Modification Rate for the most recent 3 years and include rating worksheets (ie. NCCI) Corporate: 2012: 2013: 2014: OSHA CITATIONS Has your company received any OSHA citations in the last three years? If yes, please provide: The date of the violation: The violation type (ie. Serious): What has been done to prevent similar violations:

4 SAFETY GOALS AND OBJECTIVES Do you have Corporate Safety Goals and Objectives? Do you have a written safety and health program/manual? Include a copy of your entire Health & Safety Manual Included SAFETY MEETINGS Do your supervisors hold safety meetings? If yes, how often? INSPECTIONS Do you conduct field safety inspections to determine compliance with applicable federal, state, local and company regulations/procedures? If yes, who conducts the inspection? Are inspection reports generated? If yes, who receives a copy of the report? Do you have a follow-up system to track items identified during safety inspections? SAFETY TRAINING AND ORIENTATION Do you have a documented pre-job or new employee occupational safety & health orientation program? Do you have a documented occupational safety & health Training program for newly hired or promoted first line supervisors or foremen? Who conducts training? (Name, Title) Please check all elements below that are delivered by your training program: Subject Yes No Injury/Incident/Near Miss Emergency Procedures First Aid Procedures Hazard Recognition Incident Reporting Job Hazard Analysis Respitory Protection Safety Tailgates Other-Specify Does your company hold regularly scheduled safety meetings for employees? If yes, how often? Does your company have a Drug-Free Workplace Program? DRUG-FREE WORKPLACE Does this program include the following testing? Pre-employment Random Post Incident Reasonable Suspicion INJURY/INCIDENT INVESTIGATION Does your company conduct injury, incidents and near-miss investigations? Who conducts the investigations? (name,title)

5 Any active litigation with owners/general contractors? LITIGATION INFORMATION U In the past five years has your company or its principals been involved with any of the following: Any judgments against you? Assessed liquidated damages? Any labor law violations? Ever defaulted or failed to complete a contract? Terminated prior to contract completion? License suspended or revoked? Please attach a list of 5 significant projects within the last three years to include volume, scope of work and contract amount. Please include your project list for the last 12 months. (Attach a separate sheet) Insurance Broker Name: Please review the attached sample certificate of insurance and additional insured endorsement to verify whether or not you meet the Stevens Construction Insurance Requirements. We have reviewed the attached documents and we fully meet the Stevens Construction, Inc. insurance requirements. If you checked, please indicate from the list below which Stevens Construction insurance requirements you do not meet: GCL limits of $2M per project aggregate $1M Umbrella/excess policy Business auto policy limits $1M CSL 30 days notice of cancellation Evidence of Worker s Compensation Additional insured endorsement Other: SIGNIFICANT PROJECT HISTORY ATTACH SEPARATE SHEET INSURANCE INFORMATION-ATTACH COPY OF INSURANCE CERTIFICATE

6 ADDITIONAL INFORMATION (Optional) Please provide additional information or documentation that your feel would be important for us to review during our prequalification process: GENERAL CONTRACTOR/CONSTRUCTION MANAGER REFERENCES Please list three General Contractor/Construction Manager references: CREDIT REFERENCES BANK REFERENCE

7 KEY FINANCIAL INFORMATION Please add the most recent reviewed financial statements and if more than six months old, please include most recent interim financial statements. Has your firm or any of it s principals ever filed bankruptcy? : In order for your company to be approved as a subcontractor, please ensure the following documents are included: Insurance certificate Last 12 month project experience Five significant projects within last three years Health & Safety Training Program EMR rating worksheet Reviewed financial statements and/or interim financial statements Person Authorized to sign on behalf of the organization: NAME: TITLE: SIGNATURE: DATE: