Subcontractor Prequalification Form - American Integrated Services, Inc.

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Subcontractor Prequalification Questionnaire

* AIS will request updated financial and health and safety information annually.

1.0 Subcontractor Information

* Indicates required field

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 *

Minority Business Enterprise Status *

MBE WBE DBE SBE DVBE

Certifying Agency *

Please attach copies of all certifications regarding MBE status *

Max file size: 20MB

2.0 Contractor's Licenses

State *

State *

State *

Attach Copy *

Max file size: 20MB

License No. & Classifications *

License No. & Classifications *

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

Insurance Broker *

Attach a copy of evidence of insurance *

Max file size: 20MB

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

During the past five years, has your company been assessed liquidated damages *

Yes No

Are there any judgements, claims, arbitration proceedings, or suits pending/outstanding against your firm, its officers or principals *

Yes No

Has your bonding company ever had to complete a project on your behalf. If yes, please attach details. *

Yes No

During the past five years, has your company been subject to a lien or claim of $50,00 or more *

Yes No

During the past seven years, has your firm or any principal, officer or director thereof been a party to a bankruptcy or reorganization proceedings *

Yes No

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.

Upload File *

Max file size: 20MB

Year *

Year *

Year *

Intrastate *

Intrastate *

Intrastate *

Interstate *

Interstate *

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.

Upload File *

Max file size: 20MB

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.

C. *

C. *

C. *

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) *

Pre-employment Pre-placement Job Capacity Hearing Function (Audiogram) Pulmonary Respiratory

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 *

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 *

10.4 Does your firm training program include work practices and procedures such as:

General safe work practices? *

Yes No N/A

Comment/Questions *

Equipment lock-out and tag-out (LOTO)? *

Yes No N/A

Comment/Questions *

Permit-to-work procedures? *

Yes No N/A

Comment/Questions *

Fall protection? *

Yes No N/A

Comment/Questions *

Personal protective equipment? *

Yes No N/A

Comment/Questions *

Vehicle/Driving safety? *

Yes No N/A

Comment/Questions *

Electrical equipment grounding? *

Yes No N/A

Comment/Questions *

Incident reporting and investigation? *

Yes No N/A

Comment/Questions *

Emergency preparedness and response? *

Yes No N/A

Comment/Questions *

Environmental protection? *

Yes No N/A

Comment/Questions *

Hazard identification and control? *

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 *

Submit

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