Specialty Contractor Short Form Pre-Qualification Package. All Section must be Filled Out:
GENERAL INFORMATION:
Company Name:
Trade:
Street Address:
City:
State:
Zip Code:
Contact Name:
E-mail Address:
Telephone:
Fax:
Federal Taxpayer ID No:
Number of Employees:
How many years has your firm been in business?
Are you an open-merit shop company?
Revenue for the Year 2007:
Revenue for the Year 2008:
Revenue for the Year 2009:
Current Backlog:
Current Projects under Construction:
Project/Location Contract Percent Cost to Completion
Three major project Completed within the Last Two Years:
Project/Location Contract during the last Year /Owner/General Contractor
REFERENCES:
Company Contact Phone Number Affiliation
INSURANCE REQUIREMENTS:
Have you read Attachment “Service Agreement” Insurance Requirements?
$1,000,000 General Liability
Company Owned Vehicles
Can your company presently meet these requirements?
Please list all exclusions to your insurance (I.e. E.I.F.S., Residential, etc.)
SAFETY AND HEALTH INFORMATION:
Do you have a Safety Program?
Has your company received an OSHA citation within the past three (3) years?
Citations:
Current WC Experience Mod Rate:
CERTIFICATION:
I understand that the information provided will be used to qualify us for bidding only and more information will be required before any contracts are awarded.
I understand the questions above and have answered them truthfully and to the best of my knowledge.
Name:
Title:
Company:
E-mail Address:
Date:
Service Agreement
All subcontractors shall purchase and maintain insurance of the types and in the amounts described below. The insurance shall be written by insurance companies
acceptable to Contractor and on policy forms acceptable to Contractor. The insurance companies must be lawfully authorized to do business in the jurisdiction in which
the job is located.
Workers Compensation & Employers Liability
Statutory Workers Compensation coverage for the state in which the job is located and the state of hire, if different; as well as any other state or jurisdiction as
may be required.
Employers Liability Coverage with minimum limits of not less than:
Bodily Injury by Accident $500,000 Each Accident
Bodily Injury by Disease $500,000 Policy Limit
Bodily Injury by Disease $500,000 Each Employee
If applicable to the job, coverage under the Longshore and Harbor Workers' Compensation Act; the Jones Act or other Admiralty or Maritime Law; or any other Federal
Workers Compensation and Employers Liability Laws, shall be provided.
Commercial General Liability
Commercial General Liability Coverage with minimum limits of not less than:
Commercial General Liability Coverage must be written on an "occurrence" form and include the following coverage's: Premises-Operations, Independent Contractors,
Contractual Liability, Products - Completed Operations, Personal and Advertising Injury. There shall be no limiting endorsements as respects: the scope of Contractual
Liability coverage; "X, C, U" coverage; Broad Form Property Damage coverage Including Completed Operations. There shall be no "cross suits" exclusion
which prohibits or eliminates coverage for suits or claims made against the Subcontractor by any party named as an Additional Insured. Contractual liability coverage
shall apply to claims arising out of ongoing operations as well as Products-Completed Operations and shall not be limited as respects time period.Inc. and other parties named as Additional Insured(s) above.
