SUBCONTRACTOR QUALIFICATIONS STATEMENT
Date: Enter Date
Type of Work Performed:
A. Insert Work Type
B. Insert Work Type
C. Insert Work Type
D. Insert Work Type
1) Company Name: Type Company Name
Address: Type Company Address
City: Type City
State: Choose a State
Zip Code: Enter Zip Code
Telephone: Telephone Number
Fax: Fax Number
Contact Person: Main Contact Person
Email Address: E-mail Address
2) Year Started: Enter Year
Years in Business under Present Name: Select
3) Total Number of Employees: Select Office: Select Field: Select Shop: Select
4) List Geographic Areas Covered: All Areas Your Company Covers
5) List State(s) in Which Company Holds Licenses:
A. State
License number: License Number
B. State
License number: License Number
C. State
License number: License Number
D. State
License number: License Number
6) Bank Reference:
Bank Name
Contact: Contact Person
Phone: Telephone Number
Bank Reference: Bank Name
Contact: Contact Person
Phone: Telephone Number
7) List Five Trade References:
1. Trade Reference
Phone: Telephone Number
2. Trade Reference
Phone: Telephone Number
3. Trade Reference
Phone: Telephone Number
4. Trade Reference
Phone: Telephone Number
5. Trade Reference
Phone: Telephone Number
8) List Five General Contractor References:
1. G. C. Reference
Phone: Telephone Number
2. G. C. Reference
Phone: Telephone Number
3. G. C. Reference
Phone: Telephone Number
4. G. C. Reference
Phone: Telephone Number
5. G. C. Reference
Phone: Telephone Number
9) List Three Major Projects Presently Under Construction:
A. Project:
Project Name and Address
Owner/G.C.:
Owner/G.C. Name
Contact: Project Contact
Phone: Telephone Number
Phone: Telephone Number
Start Date: Start Date Finish Date: Finish Date Contract Amount: Contract Amount
B. Project:
Project Name and Address
Owner/G.C.:
Owner/G.C. Name
Contact: Project Contact
Phone: Telephone Number
Phone: Telephone Number
Start Date: Start Date Finish Date: Finish Date Contract Amount: Contract Amount
C. Project:
Project Name and Address
Owner/G.C.:
Owner/G.C. Name
Contact: Project Contact
Phone: Telephone Number
Phone: Telephone Number
Start Date: Start Date Finish Date: Finish Date Contract Amount: Contract Amount
10) List Revenue for the Past Three Years
Private Work 2016 $ Amount
2015 $ Amount
2014 $ Amount
Public Work 2016 $ Amount
2015 $ Amount
2014 $ Amount
11) Current Backlog of Uncompleted Work: $ Amount
12) Have You Ever Failed to Complete a Project? Yes ☐ No ☐
If Yes, Explain: Please Enter Explanation
13) Do You Have a Written Safety Program? Yes ☐ No ☐
If Yes, Please Attach Copy of Program
14) Do You Require Your Field Employees to be OSHA 10 Hour Certified? Yes ☐ No ☐
If No, Explain:
Please Describe the Safety Program You Provide
15) Have You Been Cited by OSHA within the Last Four Years? Yes ☐ No ☐
If Yes, Explain: Please Enter Explanation
16) Insurance – What are Your Standard Limits of Insurance Coverage?
A) General Liability
Limit: $ Amount
Agent: Broker’s Name
B) Umbrella
Limit: $ Amount
Agent: Broker’s Name
C) Workers Compensation
Limit: $ Amount
Agent: Broker’s Name
Insurance Co.: Insurance Company
Phone: Telephone Number
Insurance Co.: Insurance Company
Phone:
Telephone Number
Insurance Co.: Insurance Company
Phone: Telephone Number
D) Are You Bondable? Yes ☐ No ☐
Surety Co.: Surety Company
Single Job Limit $ Amount
Aggregate $ Amount
Agent: Broker’s Name
Phone: Telephone Number
17) Workers Compensation Modification Rating (EMR for Last Three Years)
2016
2015
2014
Rating
Rating
Rating
18) Do You Offer Health Insurance for Your Employees? Yes ☐ No ☐
If Yes: Full Coverage ☐
Partial Coverage ☐
No Reimbursement ☐
19) Do You Have a Formal Employee Training Program? Yes ☐ No ☐
20) What Means Do You Use for Employee Training?
Please List All Means of Training
21) Do You Qualify as an Approved Disadvantaged Business Enterprise (DBE)? Yes ☐ No ☐
(Please Attach a Copy of the Certification)
22) Do You Qualify as an Approved Minority Business Enterprise (MBE)?
(Please Attach a Copy of the Certification)
Yes ☐ No ☐
23) Does Your Company E-verify in Accordance with State and Federal Statutes? Yes ☐ No ☐
24) Is Your Firm a Member of Any Trade / Business Associations?
Please Enter Trade or Businesses Association(s) to Which Your Company Belongs
25) Minimum Size of Job Your Firm Would Like to Perform $ Amount
26) Maximum Size of Job Your Firm Would Like to Perform $ Amount
28) Has your firm ever petitioned for bankruptcy, failed in business, defaulted or been terminated on a contract
awarded to you?
Yes ☐ No ☐
If Yes, Please Explain in Detail: Please Enter Explanation
29) Has your firm ever had a claim made against it for improper, delayed, defective or non-compliant, or failure
to meet warranty obligations?
Yes ☐ No ☐
If Yes, Please Explain in Detail: Please Enter Explanation
Submitted By: Your Name
Title: Your Title