Subcontractor / Vendor / Professional Services PREQUALIFICATION FORM
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1 Subcontractor / Vendor / Professional Services PREQUALIFICATION FORM GENERAL INFORMATION Company Name Address If Corporate Office check here Primary Contact Phone Estimating Contact Corporate Headquarters Other Branch Offices Design / Build Capability If, Engineering Staff is Internal External Equal Opportunity Employer Years in Business under Present Name Status Federal Identification. Dun & Bradstreet Number: Union years n-union Company Type: Corporation Partnership Sole Proprietor DBA Joint Venture Individual LLC Type of Subcontractor: *Material Provider/Consultant *For Material Provider/Consultant ONLY - Sections regarding Bonding/Safety Requirements and EMR Rating are not applicable **Installation Subcontractor/Professional Services **Installation Subcontractor/Professional Services - ALL Sections are applicable Trade: Percentage of Self-Performed Work: % What type of work would you typically subcontract out?
2 GEOGRAPHICAL REFERENCES: List states and corresponding counties where your company provides services/projects. If work is performed in all counties in a state, just list the state. State Counties MARKET SHARE OF COMPANY WORK Healthcare Residential Industrial Municipal Education Office Retail Tenant Interior Lowrise Midrise Average Contract Size: Range of Contract: to Average annual dollar volume of sales over the last five (5) years: Business Clarification (Check ALL that apply) Small Business Certified Small Disadvantaged Business (SBD) 8a Certified SDB Certified HUB Zone Small Business Owner Ethnicity (Check ONE of the following) African American Hispanic American Native American Asian-Pacific American Asian-Indian American Caucasian Ownership Type (Check ALL that apply) MBE - Minority Owned Business Enterprise Certified (Check ONE) WBE - Women Owned Business Enterprise Veteran Owned Business Enterprise If, please include a copy of all certifications relative to the ownership type(s) indicated. Disabled Veteran Owned Business Enterprise
3 INSURANCE Insurance Agent: Contact: Phone: Carrier: NOTE: Leopardo will not accept EMC as an insurance carrier Carrier A.M. Best Rating: COMMERCIAL GENERAL LIABILITY: General Aggregate (per project) 2,000,000; Products & Completed Operations Aggregate 2,000,000; Personal/Advertising Injury 1,000,000; Each Occurrence 1,000,000 IF subcontractors work includes the scopes of any demoltion, excavation, earth retention, cast-in-place concrete, precast concrete, masonry, steel, roofing, curtainwall, electrical, plumbing, fire protection, HVAC, elevator or insulation the following limits are required: General Aggregate (per project) 4,000,000; Products & Completed Operations Aggregate 4,000,000; Personal/Advertising Injury 1,000,000; Each Occurrence 2,000,000 *Additional insured on a primary basis UMBRELLA/EXCESS LIABILITY: 5,000,000 Each Occurrence IF subcontractors work includes the scopes of any demoltion, excavation, earth retention, cast-in-place concrete, precast concrete, masonry, steel, roofing, curtainwall, electrical, plumbing, fire protection, HVAC, elevator or insulation the following limits are required: 10,000,000 Each Occurrence WORKERS' COMPENSATION: Statutory Limits MINIMUM INSURANCE REQUIREMENTS *Additional insured status on a primary/non-contributory basis employing ISO Form CG /01 or 07/04 version in conjunction with ISO Form CG /01 or 07/04 version OR equivalent(s) *A Waiver of Subrogation in favor of Leopardo Companies, Inc. and others as required by contract BUSINESS AUTO LIABILITY: 1,000,000 combined single limits OR 1,000,000/1,000,000 Bodily Injury each person/accident and 1,000,000 Property Damage each accident *A Waiver of Subrogation in favor of Leopardo Companies, Inc. and others as required by contract EMPLOYER'S LIABILITY: 1,000,000 each accident; 1,000,000 each employee-disease; 1,000,000 each policy limit-disease PROFESSIONAL LIABILITY: IF performing architectural or engineering services including any design of shoring, mechanical, electrical, low voltage, plumbing and fire protection, earth retention systems, window wall systems, structural walls or elevators: 5,000,000 each claim; 5,000,000 total limit; 50,000 maximum deductible POLLUTION LIABILITY: IF performing any of the trades of painting, earthwork, demolition hazardouse substances abatement, concrete, building envelope trades (roofing, waterproofing, masonry restoration, EFIS), fire protection, plumbing, mechanical, elevator, drywall and millwork: 5,000,000 each claim; 5,000,000 total limit; 50,000 maximum deductible NOTE: UMBRELLA/EXCESS LIABILITY LIMITS CANNOT BE USED TO MEET ANY PRIMARY COVERAGE LIMIT REQUIREMENTS Does your company meet Leopardo's minimum insurance requirements:
4 SAFETY MINIMUM SAFETY PROGRAM REQUIREMENTS 1. Does your company have a safety officer / representative? Name: Contact Info: 2. What is your most recent OSHA Recordable Incident Rate (RIR)? 3. Has your company been cited by OSHA in the past 5 years? Citation date: Citation type: Standard cited: Penalty: 4. Does your company have a safety, health, and accident prevention program? 5. Does your company have a program to ensure that safety and health issues are pre-planned into each project and work operation? 6. Does your company have a safety inspection procedure that ensures resolution of safety issues? 7. Does your company have a safety and health training program (new hire orientation, safety huddles, weekly talks, etc.)? 8. Does your company have a supervisor safety training procedure (e.g. OSHA 30 hour every 5 years for crew leaders)? 9. Does your company have an accident / incident investigation and lessons learned procedure? LEGAL Has your organization ever failed to complete any work awarded to it? Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers? Has your organization filed any lawsuits or requested arbitration with regard to construction CLIENT REFERENCES nces; i.e. Owner, Architect, General Contractors Company Contact Phone
5 CREDIT REFERENCES List (3)References; i.e. Subcontractors, Suppliers, etc. Company Contact Phone LEED How many of your employees are LEED Accredited Professionals? How many projects pursuing LEED certification has your company worked on? Please list with level of certification and describe your Company's role in achieving that certification. What green technologies, products, or practices has your company used on other projects? Please explain (attached additional sheets if necessary). The undersigned certifies that the information provided herein is true and sufficiently complete so as not to be misleading. Completed By: (Signature) Name & Title (Print or Type) Date Completed: RETURN TO: Leopardo Companies, Inc Prairie Stone Parkway Hoffman Estates, IL Attention: Angela Costantino Phone
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New England Excess Exchange, Ltd. P O Box 219 ~ Montpelier, VT ~ Fax:
New England Excess Exchange, Ltd. P O Box 219 ~ Montpelier, VT 05601 800-548-4301 ~ Fax: 800-347-4935 B. MONOLINE CONTRACTORS POLLUTION LIABILITY FOR ENVIRONMENTAL AND NON-ENVIRONMENTAL RISKS POLICY HIGHLIGHTS
Venture General Contracting, LLC Pre-Qualification Form
Thank you for your interest in Venture General Contracting, LLC. In order to develop a more complete knowledge of your Company and better match future Company opportunities to your Company s capabilities
CONTRACTOR S SUPPLEMENTAL QUESTIONNAIRE
CoverX The Coverage Experts www.coverx.com FLORIDA 3050 NORTH HORSESHOE DRIVE, SUITE 200 NAPLES, FLORIDA 34014 (239) 430-9119 Telephone (239) 430-9416 Fax coverxfl@coverx.com Underwriting Email TEXAS 311
PROPOSAL LIQUID CALCIUM CHLORIDE
Gary Hammond, P.E. Commissioner of Public Works Tioga County Department of Public Works 477 Route 96 Owego, New York 13827 (607) 687-0302 Fax (607) 687-4453 Richard Perkins, P.E. Deputy Commissioner of
Address: Description:
Environmental Services Application This application is NOT an insurance policy and the insurance company affording coverage reserves the right to reject any application for any reason. If additional space
Supplier Profile Form
Supplier Profile Form All new suppliers must be qualified prior to any purchases being made. Please complete the following form and email to purchasingdept@thompsontractor.com or fax to 205-226-6203. Once