SUBCONTRACTORS

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General Company Information

Address*
Primary Contact Name*
Emergency Contact
Company Organization*

Officers/Partners/Principals & Signature Authority

Contracts #1
Change Orders #1
Contracts #2
Change Orders #2
Contracts #3
Change Orders #3
Date of Origination*

Trade Information

Trade List
Trade
% of work
Self Performed (yes or no)
Subcontracted (yes or no)
 

Employees

Employee History*
Year
Number of Field Mgmt Staff
Number of Field Workers
 
Last 3 available years
Do you use independent contractors?*
Do you use Direct Hire Agencies?*

Subcontractor/Supplier/Vendor Small Business Certification

Address*
Primary Contact Person*
Is the Company Qualified? Your business may qualify for more than one description below. Please check all that apply to your business.
Small Business
Small Disadvantaged Business (SDB)
Women-Owned Small Business (WOSB)
Veteran-Owned Small Business (VOSB)
Service-Disabled Veteran-Owned Small Business (SDVOSB)
Small Business Administration HUBZone Certified
8(a) Certified
Alaska Native Corporation or Indian Tribe
Other Small Business Affiliations
Large Business

Bonding/Surety Information

Mailing Address
Date of Last Bond Issued

Insurance Information

Please indicate your current policy limits for each for the following coverage's:
Effective Date
Does your policy's general aggregate limit apply separately to each project?
Are defense costs excluded from the general aggregate limit?
Please indicate your General Liability Policy form
Does your current General Excess and Auto Liability policies allow endorsement to name AutoBUilders and the project owner as additionally insured, stipulating the insurance afforded the additional insured's shall apply as Primary to any other insurance carried by them?
And Non-Contributory to any insurance carried by them?
Are you able to provide a Waiver of Subrogation endorsement?
Does your policy limit additional insured coverage to "ongoing operations"?

Please indicate your firm's primary point of contact for insurance related issues

Please provide the contact information for your Insurance Agent/Broker

Drop files here or
Max. file size: 50 MB, Max. files: 10.
    Please attach a SAMPLE Certificate of Insurance to evidence coverage stated together with a SAMPLE of the Additional Insured Endorsement stipulating primary coverage used by your carrier.

    Safety Information

    Experience Modification Rate (EMR) for the three most recent years
    How many man hours did your employees work?
    2021
    2020
    2019
    How many recordable accidents did your firm have?
    2021
    2020
    2019
    How many restricted (light duty) workday cases did your firm have?
    2021
    2020
    2019
    How many lost day cases did your firm have?
    2021
    2020
    2019
    Total number days away from work for lost day cases
    2021
    2020
    2019
    What was your firm's incident rate for recordable accidents?
    (OSHA recordable accidents (x) man hours worked)
    2021
    2020
    2019
    What was your firm's incident rate for time loss claims?
    (Lost workday incidents (x) man hours worked)
    2021
    2020
    2019
    Have you been cited by OSHA in the last 3 years?
    Does your company have a written Safety Program?
    (Must be available for review upon request)
    Does your company have a return to work light duty program?
    Does your company have a written substance abuse testing policy?
    Does your company review the safety management systems of your tier subcontractors?

    Licenses

    List of Licenses
    License Number
    State
    Classification
    Issuing Authority
    Exp Date
     
    Trade References
    Major Supplier Tier Sub
    Contact Name
    Phone
    Email
    Other
     
    Work in Progress Schedule
    Project
    Contract Amount
    Est. Completion
    General Contractor
    Contact Info
     
    List current and ongoing projects with approximate contract amount and anticipated completion date or attached separate lists (attach a separate sheet as needed)
    Drop files here or
    Max. file size: 50 MB.
      Completed Work Schedule
      Project
      Contract Amount
      Est. Completion
      General Contractor
      Contact Info
       
      Please list projects undertaken in the last three years. (Attach a separate sheet as needed)
      Drop files here or
      Max. file size: 50 MB.
        The following signature is from an authorized representative of the company and attests to the accuracy of the information provided above.
        MM slash DD slash YYYY
        This field is for validation purposes and should be left unchanged.