CONTRACTOR PRE-QUALIFICATION FORM

Transcription

1 Doc..: Rev../Date: C 3/28/2017 Page: 1 of 13 GENERAL INFORMATION 1 Person Completing this PQF: Title: Telephone: Fax: Address: 2 Contact for Requesting Bids: Title: Telephone: Fax: Address: 3 Contact for Contract Administration: Title: Telephone: Fax: Address: 4 Contact for Insurance Information: Title: Telephone: Fax: Self-Insured for Worker s Comp Insurance? Insurance Carrier Name: Address: Telephone: Please provide a current Certificate of Insurance per the insurance requirements provided in Section 48: INSURANCE on pages 11 and 12 of this document. 5 Company Name: Address: City: State and Zip: Telephone: Fax Number: Subsidiaries (Division of): Date business founded: Under current Management since: 6 Organization Type: Sole Owner Corporation Partnership

2 Doc..: Rev../Date: C 3/28/2017 Page: 2 of 13 7 Officers of the Company: Names Position: Telephone: President Vice President Treasurer 8 Safety Professionals: Names Title: Telephone: 9 Primary Business Activity (Describe service(s) performed in detail): Company s rth American Industry Classification System (NAICS) or Standard Industry Code (SIC): Current Industry Injury Rate for the NAIC/SIC provided: (Use the most current BLS Average for your Company s code.) 10 Company Work History Do you normally employ? Union Personnel n-union Personnel If Union, list trades/locals: Average Number of Employees: (Per year for last 3 years.) Year: Year: Year: 11 Company Paid Benefits: Do you have or provide? Select: or a. Health Insurance? b. Dental Insurance? c. Paid Vacation? d. Paid Holidays? e. Paid Sick Leave? f. Educational Reimbursement Program? g. Employee Benefit Sharing? 12 Annual Dollar Volume: Annual dollar volume for the past 3 Years: Year: Year: Year: $ $ $

3 Doc..: Rev../Date: C 3/28/2017 Page: 3 of 13 Largest job completed during the last 3 years: Your firm s desired project size: Maximum: Minimum: D&B Financial Rating: Annual Sales: Net Worth: 13 Major job(s) in progress: Please list below. Customer/Location: Type of Work: Size $M: Customer Contact: Telephone # 14 Major jobs completed in past three years: Type of Customer/Location: Work: Size $M: Customer Contact: Telephone # 15 Are there any judgments, claims or suits pending or outstanding against your company? If yes, please attach details. 16 Has the Company now or ever been involved in any bankruptcy or reorganization? If yes, please attach details. SAFETY AND HEALTH PERFORMANCE: 17 Workers Compensation Experience Modification Rate (EMR) Data: a. EMR is: Interstate Rate b. State of Origin: Intrastate Rate c. EMR Anniversary Monopolistic State Rate Date: Dual Rate d. EMR from past 3 years: Year: Year: Year: e. Provide the EMR Statistics on your Insurance Carriers Letterhead from the past three years:

4 Doc..: Rev../Date: C 3/28/2017 Page: 4 of Injury/Illness Data: a. Employee Hours Worked Last Three Years: Past 3 Years: Year: Year: Year: Hours: Hours: Hours: Hours: b. Provide your OSHA 300/300A Log Forms from the past three (3) years, and fill in the following Past 3 Years: Year: Year: Year: Number/Rates: Number: Rate: Number: Rate: Number: Rate: RAI (OSHA Recordable Cases Rate) EMR Rate NA NA NA LWDIR (Lost Time & Alternate Work Duty Rate) Total Number of OSHA Recordable Cases Lost Time Incidents (Number of Cases Resulting in Time Off Work) c. Provide the following data (excluding subcontractors) using your OSHA 300/300A Logs Forms from the past three years: Past 3 Years: Year: Year: Year: Number/Rates: Number: Rate: Number: Rate: Number: Rate: Number of Alternate Work Duty NA NA NA Cases Number of Fatalities NA NA NA tes: a. Data should be the best available data applicable to the work in this region or area. b. If your company is not required to maintain OHSA 300/300A forms, please provide information from your Worker s Compensation insurance carrier itemizing all claims for the last three years and attach to this form. 19 Has the Company received any Regulatory (EPA, OSHA, etc.) inspections in the last three years? If yes, please attach details. 20 Has the Company received any Regulatory (EPA, OSHA, etc.) citations in the last three years? If yes, please attach details. 21 Has the Company had a fatality in the last three years? If yes, please attach details.

5 Doc..: Rev../Date: C 3/28/2017 Page: 5 of 13 SAFETY AND HEALTH MANAGEMENT: 22 Highest Ranking Safety/Health Professional in the Company: Name: Title: Telephone: a. Do you have or provide a full time Safety/Health Director? b. Do you have or provide a full time Safety/Health Supervisor? c. Do you have or provide a full time Safety/Health Coordinator? d. Do you have or provide a Safety/Health incentive program? e. Do you have or provide Company paid Safety/Health training? SAFETY AND HEALTH PROGRAMS & PROCEDURES: 23 Do you have written safety and health programs? a. Management commitment and expectations? b. Employee Participation? c. Accountabilities/responsibilities for managers, supervisors, and employees? d. Resources for meeting safety & health requirements? e. Periodic safety & health performance appraisals for all employees? f. Safety Recognition Program? g. Hazard recognition and control? 24 Does the program include work practices and procedures such as: YES: NO: N/A: a. Energy Control [Lockout / Tagout {LO/TO}] b. Hot Work c. Confined Space Entry d. Accident/Incident Reporting & Investigation e. Unsafe Condition Reporting f. Occupational Injury & Illness Reporting g. Bloodborne Pathogens h. Fall Protection i. Personal Protective Equipment j. Portable Electrical/Power Tools k. Electrical Safe Work Practices l. Electrical Equipment Grounding Assurance m. Vehicle Safety n. Rigging and Heavy Equipment o. Powered Industrial Vehicles (Cranes, Forklifts, JLGs, etc.)

6 Doc..: Rev../Date: C 3/28/2017 Page: 6 of Does the program include work practices and procedures such as: YES: NO: N/A: a. Housekeeping b. Emergency Preparedness and Response Procedures (Including Evacuation Plan) c. Fire Protection d. Waste Disposal e. Environmental Spill or Leak Prevention f. Back Injury Prevention g. Scaffolding (User) h. Excavation/Trenching & Shoring i. Abrasive Blasting j. Hydroblasting 26 Are there written programs for the following: YES: NO: N/A: a. Hearing Protection/Hearing Conservation b. Respiratory Protection; Where applicable, have employees been: Trained? Fit Tested? Medically approved? c. Hazard Communication Have employees been trained in Hazard Communication? d. First Aid 27 Do you have a substance abuse program: YES: NO: N/A: a. Pre-placement Testing b. Random Testing c. Testing for Cause d. DOT Testing 28 Do you conduct medical examinations for: YES: NO: N/A: a. Pre-employment placement b. Pre-placement Job Capability c. Hearing Function {Audiograms} d. Respiratory Protection 29 Do you have personnel trained to perform first aid and CPR? a. In the space provided below, describe how you will provide first aid and other medical services for your employees and specify who will provide this service while on site:

7 Doc..: CONTRACTOR 0 C Rev../Date: File Loc.: 1 04/24/2017 3/28/2017 K:\+RECORDS CENTER Page: 7 of Do your company employees read, write, and understand English such that they can perform their job tasks safely without an interpreter? If, attach a description of your plan to assure that they can safely perform their jobs. 31 Does your Company conduct background Checks for new hires? 32 Do you hold site Safety & Health meetings for: a. Field Supervisors b. Employees c. New Hires d. Sub-Contractors Are the safety and health meetings documented? Are the safety and health meetings critiqued by management? What was the date and topic for the last meeting? YES: NO: Frequency: Date: Topic: 33 If applicable, is there a PPE Program? If so: a. Is PPE provided for employees? b. Does the PPE Program assure that PPE is inspected and maintained? 34 Do you have a corrective action process for addressing individual safety and health performance deficiencies? 35 Do you have written environmental management programs? a. Does the program include employee awareness training? b. Does the program include auditing procedures? c. Does the program include provisions for identifying physical impacts to the environment and how to control or mitigate those risks? 36 Is Environmental a full time responsibility position? 37 Has the company ever had an environmental-related violation, fine, penalty or judgment against it? 38 Is the company involved in any ongoing enforcement actions, consent agreements or litigation? If yes to questions 27 & 28 above, please give brief description of each. ENVIRONMENTAL PROGRAMS & PROCEDURES:

8 Doc..: Rev../Date: C 3/28/2017 Page: 8 of Equipment & Materials: YES: NO: N/A: a. Do you have a system for establishing applicable health, safety, and environment specifications for acquisition of materials and equipment? b. Do you conduct inspections on operating equipment {e.g., cranes, forklifts, JLG, etc.} in compliance with regulatory requirements? c. Do you maintain the applicable inspection and maintenance certification records for operating equipment? 40 Subcontractors: YES: NO: N/A: a. Do you use subcontractors? (If no, skip to #42) b. Do you use safety & health performance criteria in selection of subcontractors? c. Do you evaluate the ability of subcontractors to comply with applicable health & safety requirements as part of the selection process? d. Do your subcontractors have a written Safety & Health Program? e. Do you include your subcontractors in: Safety & Health Orientations Safety & Health Meetings Inspections Audits 41 Inspections and Audits: YES: NO: N/A: a. Do you conduct safety and health inspections? b. Do you conduct safety and health program audits? c. Do you conduct environmental inspections? d. Are corrections of deficiencies documented? SHORT SERVICE EMPLOYEE (SSE) POLICY: 42 Does your company have a SSE policy that: YES: NO: N/A: a. identifies new employees or experienced employees new to your company or new to their position? b. If yes, does the SSE policy include a mentor being assigned to the SSE? c. If yes, does it define the roles and responsibilities of the mentor? BEHAVIORAL BASED SAFETY PROGRAM: 43 Does your company implement a: behavioral based safety program that: a. requires all employees to participate in the in documented safety observations? YES: NO: N/A:

9 Doc..: Rev../Date: C 3/28/2017 Page: 9 of 13 LICENSES OR PERMITS: 44 Permits : : N/A: a. Is your company required to have any federal, state or local Permits to perform your services (e.g., NORM, Asbestos, DOT, etc.)? b. Please list type(s) of licenses/permits and state issued: SAFETY AND HEALTH TRAINING: 45 Craft Training: : : N/A: a. Have employees trained in appropriate job skills? b. Do you have a process to assess skills of your workers to assure they are qualified? (Attach explanation) c. Are employees job skills certified where required by Regulatory or Industry consensus standards? d. In the space provided below, please list the crafts which have been certified: 46 Safety and Health Orientation: New Hires: Supervisors a. Do you have a Safety and Health Orientation Program for new hires and newly hired or promoted supervisors? b. Does the program provide instruction for the following: New Worker Orientation Safe Work Practices Safety Supervisor Toolbox Safety Meetings Emergency Procedures HazWoper/Emergency Response First Aid Procedures Incident Reporting and Investigation Fire Protection and Prevention Safety Intervention Hazard Communication Environmental Awareness c. How long (time taken to complete) is the orientation program? : : : :

10 Doc..: Rev../Date: C 3/28/2017 Page: 10 of Safety and Health Training : : a. Do you know the Regulatory safety and health training requirements for your employees? b. Have your employees received the required safety and health training and retraining? c. Do you have a specific safety and health training program for supervisors? d. Are all employees trained in the work practices needed to safely perform his/her job? e. Is each employee instructed in the following: The known potential fire, explosion, or toxic release hazards related to his/her job? The process and the applicable provisions of the emergency action plan? 48 Safety and Health Training Records : : a. Do you have safety and health and crafts training records for your employees? b. Do the training records include the following: Employee Identification? Date of the training? Name of the trainer? Method used to verify understanding? c. How do you verify the training? (Check all that apply) Written Test Oral Test Performance Test Job Monitoring Other (List)

11 Doc..: Rev../Date: C 3/28/2017 Page: 11 of 13 INFORMATION SUBMITTAL CHECKLIST: Please provide ELECTRONIC copies of requested items with this completed PQF: a. EMR documentation from the Insurance Company b. Current Insurance Certificate with Ampirical Solutions, LLC requirements in Section 48 c. Recent Audited Financial Statements d. Financial Statements, Less than 3 Months e. Copies of OSHA 300/300A Logs for the past 3 years f. Example of Employee Safety & Health Training Records g. Environmental Management Program, Plan, Training, Audit/Inspection Forms (Sample) h. Document Supporting Back Ground Checks i. Safety and Health Program Manual Please validate your provided Safety and Health Program has the following included: Safety and Health Incentives Program Substance Abuse Program Hazard Communication Program Respiratory Protection Program Housekeeping Program Accident/Incident Investigation Procedures Unsafe Condition Reporting Procedure Safety & Health Inspection Form Safety & Health Audit Procedure and Form Safety & Health Orientation Safety & Health Training Program te: Ampirical checks items to be provided with PQF. This document must be printed and signed by the Contractor Company Officer. Then PLEASE copy/scan it and send it in electronically to: procurement@ampirical.com Title: Name: Date: Ampirical Solutions Contractor Approval <<For Ampirical Solutions use only!)>> a. Acceptable for Approved Contractor List b. Conditionally acceptable for Approved Contractor List c. Conditions (if any): APPROVED BY: Title: Title: Title: Title: Date: Date: Date: Date: Signature: Signature: Signature: Signature: Procurement Safety Accounting Operations

12 Doc..: Rev../Date: C 3/28/2017 Page: 12 of INSURANCE 49.1 Certificates of insurance acceptable to the Contractor shall be filed with the Contractor prior to commencement of the Subcontractor s Work. These certificates and the insurance policies required by this Article shall contain a provision that coverages afforded under the policies will not be canceled or allowed to expire until at least 30 days prior written notice has been given to the Contractor. If any of the foregoing insurance coverages are required to remain in force after final payment and are reasonably available, an additional certificate evidencing continuation of such coverage shall be submitted with the final application for payment as required in Article 10. If any information concerning reduction of coverage is not furnished by the insurer, it shall be furnished by the Subcontractor with reasonable promptness according to the Subcontractor s information and belief The Subcontractor agrees to carry and maintain the following insurance, from carriers with an A.M. Best rating of at least A-/VIII: Workers' Compensation (Including Occupational Disease) and Employer's Liability Insurance with a minimum policy limit of $1,000,000 per accident. Coverages shall apply to all employees in accordance with the benefits afforded by the statutory workers' compensation acts applicable to the State, Territory or District of hire, supervision or place where work is performed Comprehensive Commercial General Liability Insurance including Contractual Liability Coverage covering liability assumed under this Agreement, Products/Completed Operations Coverage, Broad Form Property Liability Coverage, Personal Injury Coverage and Underground, Collapse and Explosion Hazards. Policy limits shall not be less than $1,000,000 Per occurrence and $1,000,000 in the annual aggregate Comprehensive Automobile Liability Insurance covering all owned, hired, leased, assigned and non-owned automotive equipment with a combined single limit of no less than $1,000, Umbrella Liability or Excess Liability Insurance excess of all primary coverages may be used to satisfy the limit requirements for Employer s Liability Insurance, Commercial General Liability Insurance, and Comprehensive Automobile Liability Insurance. Such umbrella policy shall follow the form of those primary coverages, be in excess of those underlying policies without gaps in limits and provide coverage as broad as the underlying All insurance policies carried by Subcontractor hereunder shall name Contractor, its affiliated and subsidiary companies, and their respective directors, officers, agents and employees as additional insureds with respect to liability arising out of work performed by subcontractor. In addition, the general liability policy shall name Contractor, its affiliated and subsidiary companies, and their respective directors, officers, agents and employees as additional insureds with respect to liability for bodily injury or property damage caused in whole or in part by Subcontractor s work performed for Contractor and included in the product-completed operations hazard.

13 Doc..: Rev../Date: C 3/28/2017 Page: 13 of The Subcontractor shall cause the commercial liability coverage required by the Subcontract Documents to include: (1) the Contractor and the Owner as additional insureds for claims caused in whole or in part by the Subcontractor s negligent acts or omissions during the Subcontractor s operations; and (2) the Contractor as an additional insured for claims caused in whole or in part by the Subcontractor s negligent acts or omissions during the Subcontractor s completed operations. Subcontractor agrees to provide all insurance required by the Prime Contract All insurance policies of the Subcontractor shall include a waiver of subrogation against Contractor and its subsidiary or affiliated companies, successors, and assigns Before commencing any performance under this Agreement, the Subcontractor shall furnish Contractor with Certificates of Insurance evidencing insurance coverage and provisions provided for in this Agreement. Failure of the Subcontractor to furnish such evidence of insurance coverage shall not be considered a waiver by Contractor of such coverage The Subcontractor s insurance shall apply on a primary and non-contributory basis insurance with respect to any other insurance or self-insurance programs afforded to or maintained by Contractor, and shall not require the exhaustion of any other coverage Subcontractor shall promptly notify Contractor when any insurance policy required above is not reasonably available and shall state the reasons therefore All deductibles, self-insured retentions and self-insurance carried by the Subcontractor under its insurance program are the sole responsibility of the Subcontractor and will not be borne in any way by Contractor The Contractor shall furnish to the Subcontractor satisfactory evidence of insurance required of the Contractor under the Prime Contract WAIVERS OF SUBROGATION The Contractor and Subcontractor waive all rights against (1) each other and any of their subcontractors, sub-subcontractors, separate contractors, and any of their subcontractors, subsubcontractors, agents and employees for damages caused by fire or other causes of loss to the extent covered by property insurance provided under the Prime Contract or other property insurance applicable to the Work, except such rights as they m ay have to proceeds of such insurance held by the Owner as a fiduciary. The Subcontractor shall require of the Subcontractor s Subsubcontractors, agents and employees, by appropriate agreements, written where legally required for validity, similar waivers in favor of the parties enumerated herein. The policies shall provide such waivers of subrogation by endorsement or otherwise. A waiver of subrogation shall be effective as to a person or entity even though that person or entity would otherwise have a duty of indemnification, contractual or otherwise, did not pay the insurance premium directly or indirectly, and whether or not the person or entity had an insurable interest in the property damaged.