Albemarle Plice Department Trade Cntractr Pre-qualificatin In filling ut this pre-qualificatin statement please carefully read and fllw all instructins. If yu have any questins please cntact Jessica Pabalate at 704-332-0900 fr further instructin. Cmpleted pre-qualificatin statements shuld be submitted t Edifice, Inc., Attentin: Jessica Pabalate, 4111 Suth Bulevard, Charltte, NC 28209 r by email (jpabalate@edificeinc.cm). Please nte the fllwing are required t cmplete the pre-qualificatin statement: 1. Recent financial statements 2. Indicatin t set a minimum verall ttal gal f 10% Minrity (MWBE)/HUB participatin r greater. Further infrmatin may be required in additin t this pre-qualificatin statement based n yur respnse. These items may include additinal financial statements, prf f applicable licenses, certificatin status, safety prgram/plicy, drug and alchl prgram/plicy, additinal prject experience, and r certificates f insurance. Cmpleting this statement des nt guarantee pre-qualificatin. Albemarle Plice Department Trade Cntractr Pre-qualificatin 1
PRE-QUALIFICATION STATEMENT The undersigned certifies and agrees under ath that the fllwing infrmatin prvided herein is true, accurate and sufficiently cmplete as t nt be misleading. Cmpany Name Physical Street Address Phne Number (Area Cde first) Cntact Persn City, State, Zip Cde Fax Number (Area Cde first) Email Address f Cntact Persn Cmpany Website Address (www. ) 1. General Cmpany Infrmatin Number f years in business under current name: Has yur cmpany had any ther legal names? Yes N If yes please prvide the name(s): Is yur cmpany a subsidiary r affiliated with anther cmpany? Yes N If yes, please prvide thse names and/r affiliatins: Please list the trade package(s) yu will be bidding n if yu are t becme a pre-qualified bidder: Number f years that yu have perfrmed yur specialty trade: Value f wrk currently under cntract: Backlg value f wrk slated fr the next 12 mnths: Average annual value f wrk cmpleted the last five years: Des yur cmpany have federal, state, cunty r lcal certificatin status? Yes N DBE HUB MBE WBE SBE VB DVBE SDB Other: Certifying Agency: Will yur firm cmmit t set a gal fr this prject f 10% MWBE/HUB participatin r greater including a diverse percentage f Minrity wned business (i.e. wrkfrce, suppliers, secnd tier subs)? Yes N Des yur firm have a minrity/hub business plan? Yes N Has yur firm previusly subcntracted wrk t a minrity/hub firm? Yes N Describe yur firm s apprach t meet r exceed the MWSBE participatin gal fr this prject. Attach respnse t this pre-qualificatin statement. Albemarle Plice Department Trade Cntractr Pre-qualificatin 2
2. Crprate, LLC, Partnership and Ownership Infrmatin Is yur cmpany a crpratin, LLC, r a partnership? Please indicate such: Please prvide the fllwing: Date f Incrpratin r Partnership frmatin: State f Incrpratin r state where partnership was written: Organizatinal Structure (Please list the fllwing, full legal names) Owners Officers (CEO, CFO, President, Vice President(s), Secretary and Treasurer, etc. Partners Others authrized t represent, cnduct business fr, r sign legal dcuments n behalf f yur cmpany: Firms that experience changes in Ownership, rganizatinal structure, r material changes in assets must infrm the Cnstructin Manager (CM) prir t bidding r the award f a cntract. Has any fficer, partner, r wner f yur rganizatin ever been an fficer, partner, r wner f anther rganizatin that failed t cmplete a cnstructin cntract? Yes N If yes, please describe the circumstances: Has any fficer, partner, r wner f yur rganizatin ever been cnvicted f a crime r been invlved in lawsuit related t the failed cmpletin f a cnstructin cntract? Yes N If yes, please describe the circumstances: Has yur cmpany ever failed t cmplete a cntract? Yes N 3. Prject Experience Please prvide a list f five (5) relevant prjects f similar size and scpe (current and cmpleted) that yur cmpany has cntracted fr during the last seven (7) years. Relevant prjects include Renvatins, Plice Statins, r ther similar prjects. Relevant prjects shall als include prjects f similar size and magnitude t this jb and CM at Risk prjects as well. Albemarle Plice Department Trade Cntractr Pre-qualificatin 3
List prject name, scpe f wrk yu perfrmed, yur cntract amunt in dllars, and an email and phne number f the general cntractr r cnstructin manager cntact reference. 1 2 3 4 5 Jb name: Scpe f wrk: Cntract value: GC/CM: Phne #: Email: Jb name: Scpe f wrk: Cntract value: GC/CM: Phne #: Email: Jb name: Scpe f wrk: Cntract value: GC/CM: Phne #: Email: Jb name: Scpe f wrk: Cntract value: GC/CM: Phne #: Email: Jb name: Scpe f wrk: Cntract value: GC/CM: Phne #: Email: 4. Persnnel Assigned t the Prject Prvide relevant infrmatin n the persnnel that will be directly respnsible fr the wrk, including the lcatin f the ffice that will be primarily respnsible fr the wrk: Please list yur prject managers and superintendents and their relevant experience 5. Financial Infrmatin and References Name f Financial Institutin (Bank): Address, City, State, Zip: Cntact: Is yur cmpany currently rated with Dun & Bradstreet? Yes N Number: If yes, what is yur rating? Has yur cmpany filed fr bankruptcy r structured re-rganizatin? Yes N If the answer t any f the abve questins is yes, please describe the circumstances n an attached separate sheet. Available line f credit: $ financial institutin name: Attach an audited current (within the last 12 mnths) financial statement with the cmpleted prequalificatin infrmatin. Attached statement included? Yes N Albemarle Plice Department Trade Cntractr Pre-qualificatin 4
6. Litigatin Des yur cmpany have any current r pending claims, litigatin r lawsuits because f circumstances n current r cmpleted prjects? Yes N Current pending claims, litigatin r lawsuits with Gvernment entities may prevent prequalificatin Please prvide all infrmatin regarding yur litigatin histry, including litigatin with Owners, Cntractrs, Suppliers, and Subcntractrs. Are there any current, pending r recent (last 5 years) judgments, claims, suits, r have yu participated in any arbitratin with regards t any prjects in the last 5 years? Yes N If the answer t any f the abve questins is yes, please describe the circumstances belw: 7. Timeliness Has yur cmpany failed t cmplete a prject n time and incurred Liquidated Damages? Yes N Prvide infrmatin n the success and experience yur cmpany has with cmpleting prjects n-time. Include any recrd r histry assciated with the payment f Liquidated Damages. 8. Licensing and Classificatin Has yur cmpany ever had its license revked r are there any pending/current judgments against yur cmpany regarding yur cntractrs license? Yes N If the answer is yes, please describe the circumstances n an attached separate sheet. Current judgements will prevent the cntractr frm being prequalified Please name the licenses and license numbers that yur cmpany hlds fr the wrk yu regularly perfrm and wuld intend t perfrm n these prjects: Type f License: License Number and State: Type f License: License Number and State: Legal Authrizatin Please prvide a cpy f yur Nrth Carlina s Cntractr License r prvide a statement that guarantees yu will be able t acquire ne prir t submitting a bid n this prject. If a statement is required, the applicant shall identify the states in which they are licensed fr this type f wrk. Albemarle Plice Department Trade Cntractr Pre-qualificatin 5
9. Bnding and Capacity Surety Cmpany: Name f Agent: Agent Cntact Persn: Telephne Number fr Agent: Bnd Rate: Bnd Capacity fr a Single Prject: $ Ttal Bnd prgram capacity: $ Will yu be able t prvide a payment and perfrmance bnds fr this prject? Yes N If yes, please prvide a letter frm yur bnding cmpany. Has any bnding cmpany ever had t cmplete yur cntract wrk, because yu were unable t cmplete it? Yes N If yes, please explain the specific circumstances n an attached separate sheet. 10. Insurance Yur cmpany will be required t prvide the insurance requirements that the wner will mandate fr Edifice, Inc. At this time we ask the questin if yur cmpany can at least prvide the fllwing insurance plicies and limits fr the life f the prject. Wrkers Cmpensatin: State Statutry Requirements Emplyers Liability $500,000 Each Accident $500,000 Disease Plicy Limits (Aggregate) $500,000 Disease Each Emplyee Waiver f Subrgatin Cmprehensive General Liability Insurance Bdily Injury Liability including cntractual liability cverage assumed under the indemnity agreement f the cntract, prducts/cmpleted peratins and undergrund prperty damage XCU where applicable. $1,000,000 each ccurrence; $2,000,000 annual aggregate Prperty damage Liability including cntractual liability cverage assumed under the indemnity agreement f the cntract, prducts/cmpleted peratins and underging prperty damage XCU where applicable. $1,000,000 each ccurrence; $2,000,000 annual aggregate Edifice, Inc. and Owner named as additinal insured Cmprehensive Autmbile Liability Insurance shall be maintained by the Cntractr as t the Ownership, maintenance and use f all wned, nn-wned, leased r hire vehicles with limits f nt less then: Autmbile Liability All wned, nn-wned and hired vehicles. $1,000,000 each persn; $1,000,000 each accident Autmbile Prperty Damage Liability all wned, nn-wned and hired vehicles. $1,000,000 each persn; $1,000,000 each accident Edifice, Inc. and Owner named as additinal insured Umbrella liability limits shall nt be less than: $1,000,000 each ccurrence; Edifice, Inc. and Owner named as additinal insured Please indicate if yu can prvide the cverage utlined abve: Yes N Albemarle Plice Department Trade Cntractr Pre-qualificatin 6
11. Safety Please attach yur safety plicy r prgram with this cmpleted questinnaire. Has yur cmpany incurred any OSHA fines within the last five (5) years? Yes N Has yur cmpany had any lst time accidents within the last five (5) years? Yes N Has yur cmpany had any jbsite fatalities within the last five (5) years? Yes N If the answer t any f the questins abve is yes, please describe the circumstances n an attached separate sheet. Firms must prvide cpies f any cmplaints, safety vilatins, r reprts frm the Nrth Carlina Qualificatins Bard, OSHA, r any ther regulating agency assciated with any cnstructin prject. Please list yur cmpany s current Experience Mdificatin Rating (EMR) and fr the past three (3) years: Year Rate Year Rate Year Rate Please attach yur cmpany s substance abuse plicy r prgram. Please identify yur prcedures fr testing, pre-emplyment, randm, and after accidents. 12. Cmpany References: List fur (4) general cntractr/cnstructin manager references. Prvide as fllws: 1 2 3 4 Cmpany Name Cntact Name Phne Email 13. Signature We duly swear that all infrmatin prvided within is truthful, accurate, and shall have n cnsequence n further legal standings with Edifice, Inc. We als understand that by simply filling ut and cmpleting this statement and prviding the requested infrmatin, we will nt be deemed a pre-qualified trade cntractr. Signature f Cmpany Officer, Partner, r Owner: Type written name and title f Cmpany Officer, Partner, r Owner: Firm Name Albemarle Plice Department Trade Cntractr Pre-qualificatin 7