Vendor Pre-Qualification Application

PacifiCorp

Vendor Pre-Qualification Application

Return Completed Application To:

PacifiCorp Procurement
Attention: Vendor Administration Coordinator
825 NE Multnomah Street, Suite 400
Portland, Oregon 97232
Email: / Please Note:
·  Completed application must include a signature.
·  W-8 or W-9 form must be included with submission.
·  Incomplete applications will not be processed.

Please complete this form in detail using additional sheets as necessary. Catalogs/Brochures may be submitted as supplemental information.

Sections 1 - 5 are required for consideration

SECTION 1:

Legal Business Name:
(MUST MATCH FEDERAL TAX IDENTIFICATION NUMBER)
Contact Name/Title:
Contact E-Mail Address:
Business Address:
STREET ADDRESS CITY STATE COUNTRY ZIP CODE
Mailing Address:
(IF DIFFERENT THAN ABOVE) / ADDRESS CITY STATE COUNTRY ZIP CODE
Phone/FAX Numbers: / () / ()
AREA CODE PHONE NUMBER AREA CODE FAX NUMBER
Internet URL:

Federal Tax Identification Number:

Please provide a signed copy of your W-9.

Are there any current or previous employees of PacifiCorp that are employees, officers, or principle stockholders in your company? Yes No

If yes, please list their names and positions within your company:

Are you an affiliate or affiliated with Berkshire Hathaway or Berkshire Hathaway Energy Company? Yes No

If yes, please explain:

SECTION 2:

Company Structure

Sole Proprietor / Partnership / Corporation / Affiliate
Joint Venture / Subsidiary / Non-Profit / Division of
Year Established: / Number of Employees: / State of Incorporation:
Dunn & Bradstreet Number: / Stock Symbol:
Parent Company Name and Incorporated Address:

BUSINESS CLASSIFICATION

Are you a certified diversity enterprise? YES NO

*If Yes, please indicate which diversity classification applies

Diversity Classification:

White Female
Black Female
Black Male
Hispanic Female
Hispanic Male
American Indian/Alaskan Female
American Indian/Alaskan Male
Asian/Pacific Islander Female
Asian/Pacific Islander Male
Service Disabled Veteran Female
Service Disabled Veteran Male
Other (specify below)
*If Yes, which agency or organization issued you the certification?

Please attach your certification.

BUSINESS INFORMATION

Have you performed work for, or supplied material to PacifiCorp, its parent company Berkshire Hathaway Energy Company or any affiliates? YES NO

If yes, provide list on an attached sheet and provide your PacifiCorp or Berkshire Hathaway Energy Company or affiliate vendor ID

number(s):

FOREIGN VENDORS

Are you a foreign vendor providing services in the United States? YES NO

*If yes, please provide your U.S. Tax ID number and a copy of your W-8 form.

SECTION 3:

FINANCIAL DATA

Please indicate your gross annual sales for the last three years. The most recent year is mandatory.

$ / Year
$ / Year
$ / Year

SECTION 4:

Indicate Geographical Areas of Business Coverage

Oregon / Washington / California / Idaho / Utah / Wyoming

SECTION 5:

Please check all categories that you provide:

Goods & Materials
Abrasives / Fuses / Poles, Concrete
Adhesives / Gear Boxes / Poles, Fiberglass
Alarm/Surveillance Systems / Generators, Large / Poles, Steel
Backflow Preventers / Generators, Small Electrical / Poles, Wood
Batteries / Hardware, Miscellaneous / Pumps
Bearings / Hardware, Pole Line / Rectifiers
Belts / Hose & Hose Fittings / Relay Boards
Bird Deterrent supplies / HVAC Equipment and Supplies / Roofing/Siding/Gutter Supplies
Building Supplies / Ice Machines / Safety, Personal Protective Equipment
Capacitors / Industrial Supplies / Safety, Supplies
Chemicals / Instruments, Electrical / Scaffolding
Chemicals, Water Treatment / Instruments, Laboratory / Seals & Gaskets
Circuit Breakers / Insulators / Signage
Clothing and Uniforms / Janitorial Supplies / Spill Control Supplies
Compressors / Laboratory Instruments / Switches
Condensers / Lifting & Rigging Equipment / Switchgear
Conductor, Electrical / Lighting Supplies / Tools
Connectors / Lighting/Fixtures / Transformers, Power & Distribution
Construction Products / Locks / Transmission Structures
Control Cabinets / Maintenance, Repair and Operations Supplies / Truck Awnings
Control instrumentation / Manholes / Turbines, Gas
Cross Arms, Steel / Material Handling Equipment & Supplies / Turbines, Hydro
Cross Arms, Wood / Metal Buildings / Turbines, Steam
Distribution Structures / Meters / Turbines, Wind
Doors / Motors / Uninterruptable Power Supply
Electric Conduit (PVC, Steel, HDPE) / Office Equipment / Water Heaters
Electrical Supplies / Office Supplies / Water Supply Lines
Fasteners / Oil Water Separators / Water Treatment Materials
Fencing Materials / Pipe Products Distributor / Welding Gases & Supplies
Fiber Optic Cable / Pipe, Valves & Fittings, Plastic / Windows
Filters, Air, Water & Oil / Pipe, Valves & Fittings, Steel / Wire & Cable
Fire Protection Equipment & Supplies / Plumbing Heaters
Furniture, Office / Plumbing Supplies
Information Technology
Audiovisual Equipment / Consultant, Software Support / Radio Maintenance
Cellular Phone & Satellite Service / Copiers, Printers & Multi-Function Devices / Software Applications
Cellular Phones & Accessories / Distributed Control Systems / Software Maintenance Services
Computer Accessories / Fiber Optic Services / Software Subscriptions
Computer Equipment / IT Staffing Services / Telecommunication Engineering Services
Computer Equipment Support Services / Landline Phone Equipment / Telecommunication Equipment
Consultant, Information Technology / Landline Phone Services / Tower Maintenance Services
Consultant, Software Development / Phone Maintenance / Webhosting services
Transportation
Forklifts / Third Party Logistics Services / Vehicle, Rentals
Freight& Trucking Services / Tires / Vehicle, Utility Repairs
Fuel, Diesel / Vehicle, Filters / Vehicles, Light Duty
Fuel, Gasoline / Vehicle, Heavy Equipment Repairs / Vehicles, Medium Duty
Heavy Equipment / Vehicle, Light/Medium Duty Repairs / Vehicles, Utility
Oil & Lubricants / Vehicle, Parts
General Services
Asbestos Removal/Remediation / HVAC Services / Road Maintenance Services
Asphalt/Paving/Gravel Services / Hydroblasting Services / Scaffolding Services
Caterings/Food Services / Inspection Services, Civil Construction / Security Services
Circuit Breaker Maintenance / Inspection Services, Transformer Quality Assurance / Surveying & Mapping
Construction Services, Civil / Inspection Services, Vegetation Management Audits / Sweeping Services
Construction Services, Electrical / Insulation Services / Tank Cleaning and Repair Services
Construction Services, Mechanical / Janitorial Services / Traffic Control Services
Crane Services / Linen & Mat Service / Vegetation Management Services
Electrical Services / Machine Shop Services / Waste Disposal Services
Equipment Rental Services / Motor Repair Services / Water Craft Repairs
Excavation Services / Oil Spill Clean-up Remediation Services / Water Treatment Services
Fabrication Services / Pest Control Services / Weed Abatement Services
Fencing Installation & Repair / Plumbing Services / Welding Services
Hauling, Rigging & Unloading / Pressure Washing Services
Hazardous Materials Disposal / Protective Coating Services
Hazardous Materials Transportation / Pump Repair Services
Professional Services
Advertising Services / Environmental Consultant Services / Other Professional Services
Architectural Services / Financial Services / Photographic Services
Audio Visual Services / Geotechnical Consulting Services / Project Management Services
Civil Engineering Services / Legal Services / Real Estate Services
Electrical Engineering Services / Lobbyist Services / Safety Consultant Services
Engineering Design & Drafting / Mechanical Engineering Services / Staff Augmentation Services
Facility Services
Building & Facility Services / HVAC Services / Paving Services
Building Repair Services / Interior Remodeling Services / Plumbing Services
Electrician Services / Janitorial Services / Roofing Services
Elevator Services / Landscaping Services / Snow Removal Services
Fencing Installation & Repair / Overhead Door Services / Waste Disposal Services
Floor Covering Services / Painting Services
Power Generation - Specialty Goods and Services
Ash Handling Systems & Supplies / Conveyor Belts & Suppliers / Mining, Drag Lines
Ash Ponds / Cooling Towers & Supplies / Mining, Explosives
Backflow Preventer Services / Emission Control Systems & Supplies / Mining, Heavy Equipment
Boiler Chemicals / Gate Services / Oil Water Separator Services
Boiler Tubing / Generator Services / Power Plant Overhaul Services
Coal Handling Equipment & Supplies / Marine Diving Services / Precipitators
Condensate Systems & Supplies / Marine Dredging Services / Retention Ponds/Drainage
Construction Services, Balance of Plant / Marine, Booms and Deployment / Wind Operations &Maintenance Services
Transmission & Distribution Specialty Services
Civil Construction Services / Right of Way Services / Substation Maintenance Services
Distribution Line Repair Services / Street Light Maintenance Services / Switching Equipment
Helicopter Services / Substation Construction Services / Transmission Line Repair Services
Locating Services / Substation Equipment / Vegetation Management Services
Pole Test and Treat Services

The following sections are optional, but will assist in our review of your qualifications.

PacifiCorp Standard Insurance Coverage

PLEASE ATTACH PROOF OF YOUR CURRENT COVERAGE WHEN YOU MAIL OR EMAIL YOUR APPLICATION:

·  Worker’s Compensation

All Workers’ Compensation policies shall contain provisions that the insurance companies will have no right of recovery or subrogation against the Company, its parent, divisions, affiliates, subsidiary companies, co-lessees, or co-venturers, agents, directors, officers, employees, servants, and insurers, it being the intention of the parties that the insurance as effected shall protect all parties.

·  Employers' Liability insurance with a minimum single limit of $1,000,000.

·  Commercial General Liability insurance. The most recently approved ISO policy, or its equivalent, written on an Occurrence Basis, with limits not less than $1,000,000 per occurrence/ $2,000,000 general aggregate (on a per location and/or per job basis) Bodily Injury and Property Damage, including the following coverages:

a. Premises and Operations Coverage

b. Independent Contractor’s Coverage

c. Contractual Liability

d. Products and Completed Operations Coverage

e. Coverage for explosion, collapse, and underground property damage

f. Broad Form Property Damage Liability

g. Personal Injury Liability, with the contractual exclusion removed

h. Sudden and Accidental Pollution Liability, as appropriate

·  Business Automobile Liability insurance. The most recently approved ISO policy, or its equivalent, with a minimum single limit of $1,000,000 for bodily injury and property damage including Sudden and Accidental Pollution Liability as appropriate, with respect to Vendor’s vehicles whether owned, hired or non-owned, assigned to or used in the performance of the Work.

·  Professional Liability insurance covering damages arising out of negligent acts, errors, or omissions committed by Vendor, with a liability limit of not less than $1,000,000 each claim. Vendor shall maintain this policy for a minimum of two (2) years after completion of the Work or shall arrange for a two year extended discovery (tail) provision if the policy is not renewed. The intent of this policy is to provide coverage for claims arising out of the performance of Services under a contract and caused by any error, omission, breach or negligent act for which the Vendor is held liable.

·  Umbrella Liability insurance with a minimum limit of $5,000,000 each occurrence/aggregate where applicable to be excess of the coverages and limits required in Employers’ Liability insurance, Commercial General Liability insurance and Business Automobile Liability insurance above. Vendor shall notify Company, if at any time their full umbrella limit is not available during the term of any Contract, and will purchase additional limits, if requested by Company.

Except for Employers' Liability, Business Automobile Liability and Professional Liability insurance, the policies required herein shall include provisions or endorsements naming Company, its officers, directors, agents, and employees as additional insureds.

To the extent of Consultant’s negligent acts or omission, all policies required by any Contract shall include provisions that such insurance is primary insurance with respect to the interests of Company and that any other insurance maintained by Company is excess and not contributory insurance with the insurance required hereunder, provisions that the policy contain a cross liability or severability of interest clause or endorsement, and provisions that such policies not be canceled or their limits of liability reduced without 1) ten (10) calendar days prior written notice to Company if canceled for nonpayment of premium, or 2) thirty (30) calendar days prior written notice to Company if canceled for any other reason. All required insurance policies shall not contain any provisions prohibiting waivers of subrogation. A certificate in a form satisfactory to Company certifying to the issuance of such insurance shall be furnished to Company. Commercial General Liability coverage written on a "claims-made" basis, if any, shall be specifically identified on the certificate.

Commercial General Liability insurance coverage provided on a "claims-made" basis shall be maintained by Vendor for a minimum period of five (5) years after the completion of any Contract and for such other length of time necessary to cover liabilities arising out of the Work.

Work History

List the projects completed under the company’s present legal name within the last two (2) years for each of the types of work and/or services selected from the attached category list. (If required, attach additional information using the format shown below.)

Type of Work
Performed / Client Address
Contact Phone / Location
of Job / Contract
Value / Start/Complete
Date(s)

Safety & Environmental Program

Safety

Does your company have a formal safety program? YES NO

1.   List your company’s interstate worker’s compensation experience modification rate for past three years plus current year. If a specific state experience modifier is available, list that and identify the state.
Attach a copy of your company’s rate notice.

Year

/ Rate Modifier / State

Do you have reason to believe that your rate for the current year will vary by more than 5% from the most recent rate identified above? *YES NO

*If Yes, give reason:

2.   Using your OSHA 300 and prior 200 logs, provide Incident Rate and Lost Time Rate for the past three years plus the current year-to-date. Please provide copies of your OSHA 300/200 Logs for these years. Only copy the section with the totals (the portion which is to the right of the fold line).

YEAR / RECORDABLE RATE * / LOST TIME RATE **

* Number of recordable incidents times 200,000 divided by the number of man-hours worked.

** Number of lost time accidents times 200,000 divided by the number of man-hours worked.

Do you have reason to believe that either rate for the current year will vary by more than 5% from the most recent rate identified above? *YES NO

*If Yes, give reason:

3.   Indicate the number of fatalities your company has experienced during the past three (3) years plus the current year.

Year / Number of Fatalities
Current Year

4.   Indicate actual man-hours worked for each of the past three years plus the current year:

Year / Number of Man-hours Worked
Current Year

5.   Have you been inspected by OSHA or other industrial safety enforcement agency in the past three years and/or current year? *YES NO