Subcontractor Pre-Qualification Form 1.0 ORGANIZATION INFORMATION 1.1 GENERAL INFORMATION Company Name Mailing Address City State Postal Code Main Telephone Fax Office Address (if different from above) City State Postal Code 1.2 ENTITY (please check one only) Corporation Partnership Sole Proprietor Joint Venture Other If Other, please specify 1.2.1 Answer the following Date Business Commenced State Business commenced Owner’s Name PLEASE LIST YOUR TRADE CAPABILITIES 1.2.2 How many years has your organization been in business as a contractor? 1.2.3 How many years has your organization been in business under this name? 1.2.4 Under what other former names has your organization operated? And for how many years? 1.3 FEDERAL TAX ID NUMBER Does your company have a Disadvantaged Business Status? Yes No If yes, please check all that apply Women Business Enterprise (WBE) Minority Business Enterprise (MBE) Small Disadvantaged Business (SBA 8(a)) Veteran-Owned Business (VOB) 2.0 GEOGRAPHICAL WORK AREAS List the states in which you perform work? Do these areas require licenses? Yes No If yes, please list 3.0 LABOR RELATIONS 3.1 Labor Affiliation Please select only one: Union Non-Union List Agreements your organization is signatory to Do you perform prevailing wage? Yes No 3.2 Staffing Office Field/Trades People 4.0 REFERENCES (use the space provided or if more room is required, attach additional documents) 4.1 Supplier Reference Company Name Mailing Address City State Postal Code Contact Email Address Telephone Fax 4.2 Supplier Reference Supplier Name Mailing Address City State Postal Code Contact Email Address Telephone Fax 4.3 Bank Reference Bank Name Mailing Address City State Postal Code Contact Email Address Telephone Fax 4.4 Surety (if applicable) Name Mailing Address City State Postal Code Contact Email Address Telephone Fax 4.5 Insurance (Please attach a copy of your company’s current insurance policy certificate) Name Mailing Address City State Postal Code Contact Email Address Telephone Fax Please provide information on the last two projects worked 5.0 Project Name Location GC/CM Name Contact Phone Email Contract Value 5.1 Project Name Location GC/CM Name Contact Phone Email Contract Value 6.0 FINANCIAL INFORMATION 6.1 Annual Volume of work for last three years Enter Year: 20__ 20__ 20__ $ $ $ 6.2 Value of Projects underway or projected for this year $ 6.3 Bonding Capacity Is your company presently bonded or have the capability to become bonded? Yes No What is your Bonding Capacity? Per Job Aggregate 6.4 Project Bidding Information Please provide your bidding limits: (Max $) Do you subcontract any portion of your work? Yes No If yes, please list portions of work usually subcontracted Health, Safety and Environmental Information (HSE) Please fill-out completely as possible. (please print or type) If not applicable, please mark N/A Your firm’s Health, Safety & Environmental (HSE) performance for the last three years will be considered in this pre-qualification evaluation with emphasis given to the most recent year’s performance. Please provide the following HSE related information: 1. List your firm’s interstate or intrastate (if applicable) Experience Modification Rate (EMR) for the three most recent years, as evidenced in Workman’s Compensation Insurance premiums: Year Year Year Rate Rate Rate For the EMR to be satisfactory, the rate established by the National Council on Compensation Insurance (NCCI) or state rating bureau (if applicable) should be no greater than 1.2; Please check this box if your company has less than the minimum number of employees required by law to carry workers’ compensation insurance or if your company does not have an EMR. (If checked, please provide a letter from your Insurance Company or WCB stating this) 2. Please list any regulatory agency (e.g., OSHA, SH&S, EPA, OH&S, EC, state/ provincial agencies, etc.) safety or environmental citations or notices of violation, reportable spill events, sanitation code violations, or other governmental indications of an HSE incident1 received by your company during the previous three years. Please attach a copy of each or a summary describing the incident and how it was resolved. 3. Do you have a written Health & Safety program? (HSE – Health, Safety, Environmental) Yes No If yes, please attach a copy or a summary of your program, including any HSE, safety, or environmental policy or mission statements you may have. 4. Do you have an orientation program for new hires? Yes No 5. Do you have a program for newly hired or promoted foreman and supervisors? Yes No 6. Is OSHA 30 required for Supervisors/Foremen? Yes No 7. Do you hold employee “toolbox” HSE meetings? Yes No If yes, how often? Daily Weekly Bi-Weekly Monthly As Needed 8. Do you conduct pre-task job hazard analysis (JHA) planning meetings with employees? Yes No If yes, attach a sample. 9. Do you conduct workplace HSE inspections? Yes No If yes, who conducts this inspection? If yes, how often? Daily Weekly Bi-Weekly Monthly 10. Please identify the most senior executive/manager directly responsible for HSE program management and implementation at your company: Name Title Reports to 11. Please identify the person who would be the point of contact for Estimating projects: Name Title Phone #'s Email This Form was completed by: Submitted By Date Signature Title Telephone Fax Email Address Upload any additional documents Who We Are What We Do Who We Serve Blog Careers Contact Us 2021 Copyright. All rights reserved.