Subcontractor Prequalification Form

Company Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Union *

Yes No

If yes, which? *

Total Number of Employees *

Office *

Field Supervisory *

Field Labor *

Date *

Estimating Contact *

Email *

Phone Number *

Type of Company *

List trades performed with own forces *

Certifying Agency *

Please attach copies of all certifications regarding MBE status *

Max file size: 20MB

2.0 Contractor's Licenses

State *

Attach Copy *

Max file size: 20MB

License No. & Classifications *

3.0 Surety Information

Surety *

Bond Rate *

Please attach letter from Surety evidencing bonding capacity *

Max file size: 20MB

Broker *

Single Project *

Aggregate *

4.0 Insurance Information

5.0 Credit References

Company *

Telephone *

Company *

Telephone *

Company *

Telephone *

Contact *

Email *

Contact *

Email *

Contact *

Email *

6.0 Project References - Project must have completed within last 3 years

Client *

Telephone *

Scope *

Original Amount *

Completion Date *

Contact *

Email *

Change Orders *

Client *

Telephone *

Scope *

Original Amount *

Completion Date *

Contact *

Email *

Change Orders *

Client *

Telephone *

Scope *

Original Amount *

Completion Date *

Contact *

Email *

Change Orders *

Largest Project Completed - Last 3 Years *

Please attach copy of most recent reviewed or audited financial statements *

Max file size: 20MB

Current Backlog *

7.0 Claims

7.1 Health and Safety Statistical Information

List your company’s Worker’s Compensation (WC) Experience Modification Rate (EMR) for the three (3) most recent year. Provide a letter from your WC insurance carrier certifying the below EMRs. If your firm does not qualify for OSHA or EMR reporting, please provide Loss Run and EMR Exemption documentation.

Year *

Intrastate *

Interstate *

Please consolidate your firm’s injury and illness data for the last 3 years and complete the table below. The information provided must be for your company as a whole, not an individual office location. For U.S. operations, provide copies of your OSHA 300 and 300A logs for the last 3 years.

Year *

A. Average Number of Employees *

B. Number of Fatalities *

Year *

A. *

B. *

Year *

A. *

B. *

C. Number of cases that involved days away from work, or cases with job transfer or restriction, or both.

8.0 Health and Safety Performance

8.1 Does your firm employ a full-time Health and Safety representative? *

Yes No N/A

Name *

Phone *

Title *

Email *

8.2 Have your firm been cited by an Occupational Safety & Health or Environmental Enforcement Agency in the past 3 years? *

Yes No N/A

Comment/Questions *

If YES, please provide details *

8.3 Does your firm have a formal Health and Safety policy or manual in place? *

Yes No N/A

Comment/Questions *

If YES, please provide a copy of the Policy and a copy of the Table of Contents of the Manual. *

Max file size: 20MB

8.4 Has any employee from your firm or your firm ever been barred from working on any site due to a Health & Safety violation? *

Yes No N/A

Comment/Questions *

If YES, please provide details *

8.5 Does your firm have a drug and alcohol screening/testing program in place? *

Yes No N/A

Comment/Questions *

If YES, does your drug and alcohol program include the following? (Check all that apply) *

Pre-employment Testing Post-accident Testing Testing for Cause Random Testing

8.6 Does your company have an ongoing medical surveillance program as required by applicable governmental regulations? *

Yes No N/A

Comment/Questions *

Do you conduct medical examinations for? (Check all that apply) *

8.7 Does your firm have a Defensive Driving program (behind the wheel) for all drivers? *

Yes No N/A

Comment/Questions *

9.0 Field Health and Safety

9.1 Does your firm develop site-specific Health & Safety plans? *

Yes No N/A

Comment/Questions *

9.2 Does your firm conduct pre-start and/or tailgate safety meetings? *

Yes No N/A

How often? *

Daily Weekly Monthly None

Comment/Questions *

9.3 Does your firm conduct a hazard assessment prior to staring projects? *

Yes No N/A

Comment/Questions *

9.4 Does your firm conduct self-inspections and audits and document them? *

Yes No N/A

Comment/Questions *

9.5 Do your employees have the authority to stop work for safety reasons? *

Yes No N/A

Comment/Questions *

9.6 Does your firm have a written process to report, investigate, and record incidents? *

Yes No N/A

Comment/Questions *

If YES, Does your process provide a technique for root cause analysis? *

Yes No

9.7 Does your firm have a behavior-based safety (BBS) process in place? *

Yes No N/A

Comment/Questions *

9.8 Does your firm have a written process for Short Service Employees (SSE)? *

Yes No N/A

Comment/Questions *

9.9 Does your firm have a preventative maintenance program on all of your equipment? *

Yes No N/A

If YES, how is this accomplished? *

9.10 How are equipment deficiencies communicated to the staff that use the equipment? *

Yes No N/A

Comment/Questions *

10.0 Training

10.1 Does your firm have a HES orientation program for newly hired employees? *

Yes No N/A

Comment/Questions *

10.2 Have your employees received the local regulatory required HES training and retraining? *

Yes No N/A

Comment/Questions *

10.3 Does your firm provide specific supervisory HES training for new supervisors and refresher training for existing supervisors? *

Yes No N/A

Comment/Questions *

Form Completed By *

Phone Number *

Attachments
MBE Certifications
Contractors License
Evidence of Insurance
Surety Letter
Most Recent Audited/Reviewed Financial Statement
EMR Documentation
Health & Safety Policy or Table of Contents of H&S Plan

Name *

Phone Number *

Subcontractor Prequalification Questionnaire

1.0 Subcontractor Information

2.0 Contractor's Licenses

3.0 Surety Information

4.0 Insurance Information

5.0 Credit References

6.0 Project References - Project must have completed within last 3 years

7.0 Claims

7.1 Health and Safety Statistical Information

8.0 Health and Safety Performance

9.0 Field Health and Safety

10.0 Training