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 2005:
Revenue for the Year 2006:
Revenue for the Year 2007:
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.
