Contractor Questionnaire – Financial Information Required

General Information (Required)

Company Name / Date Company Established
Physical Address
Form of Business / □ Sole Owner
□ Partnership
□ Corporation
□ LLC
□ LP
□ Other
Minority Owned / □ Yes
□ No
Mailing Address
□ Check Here if Same as Above
Union Affiliation / □ Yes
□ No
Full Time Employees
Web Address
Federal Tax ID #

Contact Information (Required)

Contact Area / Contact Name / Phone / Email
General
OQ
□ NA
□ Use General
PHMSA Drug/Alcohol
□ NA
□ Use General
Health and Safety
□ NA
□ Use General
Environmental
□ NA
□ Use General
Insurance
□ NA
□ Use General
Financial
□ NA
□ Use General

Parent Company/Affiliate Companies (Optional)

Name of Parent Company
□ Check Here if NA / Affiliate Companies
□ Check Here if NA
Physical Address
Mailing Address
□ Check Here if Same as Above
Web Address

Products/Services (Required)

NAICS Code / Primary / States Where You Provide Products/Services
(Circle all that apply)
Secondary / Pacific Northwest
(AK,ID, OR, WA)
Pacific South
(AZ, CA, HI, NV)
Rocky Mountain
(CO, MT, ND, NM, SD, WY, UT)
Central Plains
(IA, KS, MO, NE)
Southwest
(AR, LA, OK, TX)
Southeast
(AL, FL, GA, KY, MS, NC, SC, TN)
Great Lakes
(IL, IN, MI, MN, OH, WI)
Mid-Atlantic
(DE, MD, NJ, PA, VA, WV)
Northeast
(CT, MA, ME, NH, NY, RI, VT)
SIC Code
(optional) / Primary
Secondary
Note:
For assistance in identifying the appropriate codes above, the following websites may be of help:
NAICS Code

SIC Code

What principle line of work do you propose to perform for Spectra Energy?
(Circle all that apply)
Aerial Pipeline Crossing
Air Compressor Service
Anode Installation (excavation)
Anode Installation (no excavation)
Archeological/Geological Survey
Asbestos Abatement
Audio/Visual Services
Aviation Services
Blasting
Boat Service/Rental
Boiler Service
Boiler Service (w/confined space)
Cable Work (power wires)
Cable Work - IT type (> 2 stories)
Cabling Work - IT type (< 3 stories)
Cafeteria Services, Catering
Camera/Borescope Inspection
Cathodic Protection Installation
Cathodic Protection Surveys / Inspections
Chemical Cleaning
Civil/Dirt Work
Coffee Service
Communication Tower Work (< 3 stories)
Communication Tower Work (> 2 stories)
Computer Service
Concrete Work
Consulting - hands on machinery
Consulting Services
Crane Service and Rigging
Cryogenics
Delivery Services (Industrial)
Delivery Services (Office)
Diving Services
Drilling and Boring
Electrical Work (energized work < 480 volt)
Electricity Generation and Transmission
Emissions Testing (< 3 stories)
Emissions Testing (> 2 stories)
Environmental Remediation
Equipment and Trailer Leasing
Erosion Control
Excavation (near underground systems)
Excavation - hand
Fabrication Offsite
Fabrication on-site
Fencing / Fire Protection Equipment Services – Onsite
Gas Evacuation
Gas Well Services
General Construction - Building Installation
General Construction - Carpentry
Generator Services (< 480 volt)
Generator Services (> 480 volts)
Ground Surface Restoration (ROW)
Hazardous Material/Waste/PCB Transportation
Hazardous Waste/PCB Material Treatment and Disposal
Heat Treating/Stress Relieving
Herbicide Application
High voltage electrical work (energized work > 480 volt)
Hot Taps
HVAC Services (< 3 stories)
HVAC Services (> 2 stories)
Hydro-Vac Excavation
Hydrostatic/Pressure Testing
In-service Casing - Removal, Installation, Cleaning
Industrial Hygiene
Inline Tool Work
Insecticide Application
Inspection - site
Interior Work - Carpet, Tile, DTcor, Painting
Janitorial
Large Equipment Installation/Repair
Lawn and Grounds Maintenance, Landscaping
Lead Abatement
Leak Survey
Line Locating - probing
Line Locating - with instrumentation
Low Voltage Instrumentation
Material Handling
Mechanical (Millwright, Pipe Fitter)
Meter Work
NDE/Radiography
Non-Hazardous Waste/Material Treatment and Disposal
Odorant Survey
Office Equipment Services
Overhead Crane/Hoist Maintenance
Paving and Resurfacing
Pipeline Coating
Pipeline Construction / Pipeline Operations
Pipeline Recoats, Anomalies, Clock Spring
Pipeline Rehab
Piping/Vessel Insulation
Plant Construction
Plumbing
Power Washing
Refractory Repair (w/confined space)
Refractory Work
Regrouts
Roofing (< 3 stories)
Roofing (> 2 stories)
ROW Clearing and Grubbing
ROW Mowing
ROW Mowing (flat ground w/ no above ground pipe)
Rug Rag Service
Sandblasting
Security Equipment Maintenance
Security Services
Shoring Work
Snow Removal (< 10' from above ground gas facility)
Snow Removal (> 10' from above ground gas facility)
Soil Sampling (by hand)
Soil Sampling (power equipment)
Spill/Emergency Response
Staffing
Stopple Service
Structure Demolition
Survey Work
Switch Gear Maintenance
Tank/Equipment Cleanout
Torqueing/Tensioning
Traffic Control
Tree Maintenance
Turbine/Compressor/Engine Services
Unit Overhaul
Vacuum Truck Services
Valve & Operator Installation/Maintenance
Vehicle Radio Installation
Water Well Services
Welding on live gas facilities
Window Washing (> 2 stories)
Work at Vendor facility

Environmental, Health and Safety Information (Required)

Please submit a copy of your OSHA 300 Logs

□Check here if your company is not required to maintain OSHA 300A logs. In this case, you are only required to provide the EMR data. / 2011 / 2010 / 2009
Experience Modification Rate (EMR)
Number of Health and Safety Citations/Violations
Number of Health and Safety Charges/Convictions
Number of Environmental Citations/Violations/Orders
Number of Environmental Charges/Convictions
Hours Worked
Total Number of Deaths
“G” on 300A log
Total Number of Cases With Days Away From Work
“H” on 300A log
Total Number of Cases With Job Transfers or Restrictions
“I” on 300A log
Total Number of Other Recordable Cases
“J” on 300A log
Definitions:
Lost Workday Case – incident/case which, as a result of a work-related injury/illness, affects the injured employee to the extent that days must be taken off from the job for medical treatment or recuperation.
Restricted Workday Case – incident/case which, as the result of a work-related injury/illness, an employee or health care professional keeps, or recommends keeping, an employee from doing the routine functions of his/her job or from working the full workday that the employee would have been scheduled to work before the injury/illness occurred.
Other Recordable Cases – incident/case that does not fall into the category of lost workday case, restricted workday case or fatality.

Financial Information (Required)

Please submit the following information from your most recent completed annual financial statements:
Data reported for fiscal year:
Current Assets
Fixed Assets (Property, Plant and Equipment)
Total Assets
Goodwill (if applicable)
Current Liabilities
Long-term Debt
Short-term loans, notes, and current portion of long term debt
Total Equity
IF Total Equity (above) is less than $50M, enter the following:
Cash from Operations OR Net Income (circle one)
IF Total Equity (above) is greater than $50M, enter the following:
Earnings before income taxes (EBIT)
Depreciation
Interest expenses
Source of the above provided financial data: Audited with clean opinion by auditing firm, Reviewed and compiled by auditing firm, or Unaudited. (Circle one) If results have been audited, supply a copy of auditor’s opinion.
Definitions:
All terms used above are defined in terms of GAAP.
Note: This information will be used for the sole purpose of allowing Spectra Energy to evaluate the financial strength of your company. None of this information will be released or reported to any other party.

Note: All information must be provided in order for this questionnaire to be processed.

Please return completed questionnaire and OSHA 300 Logs to:

(preferred)

OR

Or fax to 281-404-7161

Attn: SET Contractor Approval Representative

OR

Veriforce, LLC

ATTN: SET Contractor Approval Dept

19221 I-45 South, Suite 200

Shenandoah, TX 77385

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