SUBCONTRACTOR QUALIFICATIONS STATEMENT
Date:
Major Trade:
1) Company Name:
Address:
City: State: Zip Code:
Telephone: Fax:
Contact Person:
2) Years in Business:
3) Total Number of Employees: Office: Field: Shop:
4) List Geographic Areas Covered:
5) List Trades and State(s) in Which Company Holds Licenses:
License Number:
License Number:
License Number:
License Number:
6) List Major Services and/or Products Provided in Order of Expertise:
1. % Subcontracted: 5. % Subcontracted:
2. % Subcontracted: 6. % Subcontracted:
3. % Subcontracted: 7. % Subcontracted:
4. % Subcontracted: 8. % Subcontracted:
7) Bank Reference:
Contact: Phone:
Bank Reference:
Contact: Phone:
8) List Three Trade References (Contact & Phone):
1. Phone:
2. Phone:
3. Phone:
9) List Three Major Projects Presently Under Construction:
Project: Owner:
Contact: Phone:
Start Date: Finish Date: Contract Amount:
Project: Owner:
Contact: Phone:
Start Date: Finish Date: Contract Amount:
Project: Owner:
Contact: Phone:
Start Date: Finish Date: Contract Amount:
10) List Revenue for the Past Three Years:
20 20 20
Private Work $ $ $
Public Work $ $ $
11) Current Backlog of Uncompleted Work: $
12) Attach Financial Statement, Include Most Recent Copy on Auditors Letterhead.
13) Have You Ever Failed to Complete a Project? Yes No
If yes, explain:
14) Are You Signatory to Any Labor Agreement? Yes No
Which Trades?
15) Do You Have a Written Safety Program? Yes No
(If Yes, Attach Copy of Program)
16) Do You Require Your Field Employees to be OSHA 10 Hour Certified? Yes No
(If No, Please describe Safety Training you provide)
17) Have You Been Cited by OSHA Within the Last Four Years? Yes No
If yes, explain:
18) Insurance – What are Your Standard Limits of Insurance Coverage?
A) General Liability
Limit: $ Insurance Co.
Broker: Phone:
B) Umbrella
Limit: $ Insurance Co.
Broker: Phone:
C) Design/Build
Limit: $ Insurance Co.
Broker: Phone:
D) Workers Compensation
Limit: $ Insurance Co.
Broker: Phone:
E) Are You Bondable? Yes No
Surety Co.
Single Job Limit $ Aggregate $
19) Workers Compensation Modification Rating (EMR for Last Three Years)
20 20 20
20) Do you offer Health Insurance for your Employees? Yes No
If Yes: Full Coverage Partial Coverage No Reimbursement
21) Do You Have a Formal Employee Training Program? Yes No
22) What Means Do You Use for Employee Training (indicate all that apply)
In House Training Programs Yes No
Gould Institute (ABC) Yes No
Trade School / Apprenticeship Program Yes No
Continuing Education Programs Yes No
Seminars and Workshops Yes No
23) Do You Qualify as a SOMWBA Approved Minority Business Enterprise (MBE)?
Yes No
Do You Qualify as a SOMWBA Approved Women Owned Enterprise (WBE)?
Yes No
Do You Qualify as a Small Business Enterprise?
Yes No
24) Does Your Company Have Any Particular Specialized Areas of Expertise?
25) Is Your Firm a Member of Any Trade / Business Associations?
26) Minimum Size of Job Your Firm Would Like to Perform $
27) Maximum Size of Job Your firm Would Like to Perform $
Submitted By:
Title:
Marc Truant & Associates, Inc.½ Spring 2006 ½ Subcontractor Qualifications Statement ½ Page 1 of 5