Download - In order to develop a more complete knowledge of your ......Resume’s for key office personnel and field supervisors Copy of your COI (certificate of Insurance) Copy of your insurance

Response Received:

capabilities please complete this form and return to: Fax:E-Mail: Phone:

Name of Company:

Street Address:

City/State/Zip:

Phone: Fax: Website:

Company Contacts: Please Provide an Executive, Accounting Manager, and Sales Manager

Name/ Title Phone/ Fax Cell E- MailPh:Fax:Ph:Fax:

MBE WBE DBE MBE/WBE/DBE Certified by:(Please attach copies of all certifications)

Is your Company:

TRADES: Please list the trade(s) that your Company is interested in bidding

Year Company Started: Type of Company: Corp. Partnership Proprietorship Sub S. Corp.

State of Incorporation:

Federal ID No.:

Date of Incorporation:

(attach list if needed) List the corporate officers, partners, proprietors, members and shareholders of more than 5% of the stock of your Company:

Name Year of Birth Position Percent Owner%

%

%

A.

B.

C.

Under what other names has your Company operated?

How many people does your Company presently employ? Home Office Field Supervisory Trades people

Have any of the Owners, officers or major stockholders of your Company ever been indicted or convicted of any felony or othercriminal conduct? Yes NoIf yes, please explain:

Has your Company or any Owners, officers or major stockholders ever been suspended, disbarred or otherwise precluded frompursuing public work or ever been found to be non-responsive by a public agency? Yes NoIf yes, please explain:

Has your Company ever had a claim made against it for improper, delayed, defective or non-compliant work or failure to meetwarranty obligations? Yes NoIf yes, please explain:

State Unemployment Insurance No:

Has your Company or any of its principals ever petitioned for bankruptcy, failed in business, defaulted or been terminated on a

contract awarded to you? Yes No

If yes, please explain:

Subcontractor Prequalification

- 1 -Subcontractor Prequalification.doc 7/12/17

SUBCONTRACTOR PREQUALIFICATION STATEMENT

Yes No

Does your Company have any outstanding judgments or claims against it? Yes No

Please list any litigation brought against your Company in the past five (5) years asserting that you failed to make payments to

anyone.

List the geographical areas in which you work:

Enter as No. 1 the size of project you are most competitive in performing; then indicated in preference order (2, 3…) other sizeprojects you are capable of performing:

Under $100,000 $200,000 - $500,000 $1,000,000 - $5,000,00

$100,000 - $200,000 $500,000 - $1,000,000

Check all building types on which your Company has worked:

High Rise Office BuildingMid Rise Office BuildingDesign Build/ Design Assist

HealthcareHigh Tech LabsMission Critical Facilities

Corporate InteriorsHotels/ Motels/HospitalityRestaurant/Fast-Food

% What percentage of the Company’s work is normally subcontracted?

What is the largest contract your Company has completed?What work do you typically subcontracted?

Project name and scope:

Amount $ Year

Amount $

No. of Projects

Is your Company or any of its owners, officers or major shareholders currently involved in any arbitration or litigation?



201620172018

% % % % % % % % % % % %

What is the largest dollar volume job you expect to do during this year?

What is your expected annual volume this year: $

MBE/WBE Participation in work which you subcontract (average last 3 years)MBE WBE % %



201620172018

201620172018

Project name and scope:

Yes No

Remarks:

Attach a copy of your W-9

BONDING INFORMATIONA.

Name of Surety Phone

B. Bonding Capacity: Per Job $

Date of Last Bond:

Dated at this day of Two Thousand and

Key Contact Person

Aggregate: $

Amount: $

C. Please list the persons or entities that provide indemnification to your Surety:

provided herein is true and sufficiently complete to not be misleading.

Subscribed and sworn before me this

Notary Public:

Agent/Broker:

Contact: Phone:

Attach a copy of your Certificate of Insurance

My commission Expires:

INSURANCE INFORMATION

Attach a copy of your latest audited financial statement.and will be treated confidentially).If the attached financial statement is not for the identical Company named above, explain the relationship and financialresponsibility of the Company whose financial statement is provided:



(Your financial statement is strictly for BC Commercial, Inc.’s use

Name of your bank:

Address:

Phone:

Line of Credit: Amount $

UCC Filing?

Your Company’s Dunn & Bradstreet Number: Rating: Date of Dating: Pay Record

How is credit secured?

Available $ Expiration Date:

Contact Person:

We have attempted to answer all questions in a full and complete manner to assure that our answers are not in any respectmisleading, by either expressing ourselves in a misleading or ambiguous manner or omitting information. We recognize thatBC Commercial, Inc. will be relying on the accuracy of the information and our responses in this questionnaire in deciding whetherto permit us to bid and in awarding work to our Company.

Name of Company:

Completed by:Must be an Officer of the Company

Title:

Being duly sworn deposes and says that the information

day of , 20

I, an authorized representative of

SUPPLIER REFERENCE RELEASE FORM

Date: Name Title

Contact Phone No:



understand that BC Commercial, Inc. will check references, as a part of the Subcontractor Pre-Qualification process.I release BC Commercial, Inc. and all providers of information from any liability as a result of furnishing and receivingthis information.

I give permission for the representative of BC Commercial, Inc. to contact those listed below for business references.Signed:

List two of your major Suppliers:

Company Name:

Contact & Title:

Co. Address:

Company Name:

Contact & Title:

Co. Address:

Company Main Phone No:

Fax:

E-Mail:Contact Phone No:


Fax:

E-Mail:

Company Name:

Contact & Title:

Co. Address:

Company Name:

Contact & Title:

Co. Address:Company Name:

Contact & Title:

Co. Address:

Contact Phone No:


Fax:

E-Mail:

List three General Contractors / Construction Managers you do business with:

Contact Phone No:


Fax:

E-Mail:

Contact Phone No:


Fax:

E-Mail:

your insurance carrier or state fund (on their letterhead) verifying the EMR data.1.

2018Year Rate

2.

3.

Any WILLFUL OSHA violations? Yes No Yes No

Please give a brief description of the violation(s); use additional paper if necessary:

Yes No If yes, please give a brief description of the circumstances:

4. Do you have a qualified person responsible for safety within your Company? Yes No Please describe his/her qualifications:

5. Yes No Frequency:

6. Do you have a written Company Safety Policy and Program and will you provide copies if requested: Yes No

7. Yes No If Yes, please check which are included in the policy:

Pre-hire/Initial Employment

8. Yes No

9. Yes No

Yes No



List your Company’s Workers’ Compensation Experience Modification Rate for the most recent three years. Attach a copy of

Attach a copy of your last three years of OSHA 300 logs use the OSHA 300 Logs to fill in the number of cases for each of thefollowing categories: (NOTE: please mark out the names of the injured parties).

Note: Items in parenthesis come from your OSHA 300/200 log 2018 2017 2016

2017Year Rate

2016Year Rate

SAFETY INFORMATION FORM

Number of fatalities (Column G from 300) or (Columns 1 + 8 from 200)

Number of lost & restricted workday cases (Column H + I) or (Columns 2 + 9)

Number of medical treatment cases (Column J) or (Columns 6 + 13)

Number of lost workday cases (Column H) or (Columns 3 + 10)

*Employee Hours Worked

**OSHA Recordable Incidence Rate

***OSHA Lost Workday Incidence Rate

*Employee Hours Worked = total number of hours worked during the year by all employees**Recordable Incidence Rate = [G, H, I & J] or [1, 2, 6, 8, 9, 13] x 200,000 / Employee Hours Worked***Lost Workday Incidence Rate = [H] or [3 + 10] x 200,000 / Employee Hours Worked

How many OSHA violation(s) has your Company received in the last three years?

2018Year # of Violations



Any SERIOUS OSHA violations?

Any employee deaths in the past 3 years?

Does this person do safety inspections on all of your projects:

Does your Company have a substance abuse policy:

Random Cause Periodic Post Accident/Incident

Do you have a return to work/light duty program: If Yes Please describe:

Have you ever implemented 100% fall protection:

If requested can you provide us with a site-specific program addressing the fall hazards in your work?

Safety Information Form

10. Do you require documented safety meetings for your employees? Indicate which, and how often.

Yes

Yes

Yes

Yes

No

No

No

No

Frequency

Frequency

Frequency

Frequency

11. Yes No

12.

Yes No

13. Yes No If yes, please list training provided.

14. Yes No

15. Yes No

16. Yes No

17. Yes No

18. %#

Signature: Name Title Date



Field Supervisors:

New Hires:

Employees:

Subcontractor/Vendors:

Does your Company provide safety training for all employees:

If yes, please list training provided:

Do you have home office representatives (not directly involved in the project) who will visit and audit the project for safety?

Frequency

Does your Company set annual safety goals?

Does your Company have a program recognizing your employees for safety performance excellence?

Does your Company have a disciplinary program in place for safety violations?

Does your Company review the safety management systems of your sub-subcontractors?

Does your Company conduct accident/incident investigations?

Copies of MBE, WBE, DBE Certificates (if any)Audited Financial StatementW-9 FormResume’s for key office personnel and field supervisorsCopy of your COI (certificate of Insurance)Copy of your insurance carrier or state fund (on their letterhead) verifying the EMR data. OSHA

Pg. 1Pg. 3Pg. 3Pg. 3Pg. 3Pg. 4

Notarize & Sign Subcontractor PreQualification StatementComplete & Sign Supplier Reference Release FormComplete & Sign Contractor Reference Release FormComplete & Sign Safety Information Form

Pg. 3Pg. 3Pg. 4Pg. 6

List how many and what percentage of staff who have completed an OSHA 30 Hour Training Program:

The undersigned warrants and represents the data provided is accurate in all respects.

Name of Company: Prepared by:

At tachment Check l is t :

S ignature Check l is t :

Download - In order to develop a more complete knowledge of your ......Resume’s for key office personnel and field supervisors Copy of your COI (certificate of Insurance) Copy of your insurance

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