Form for Subcontractor Qualification
Multi-Institutional Academic Health Science and Research Center
Evansville, Indiana
*Please note we have identified information and questions that are mandatory. These items will be required or your bid may be disqualified. Additional items are identified as informational and bidders will have 30 days after named the successful bidder and/or prior to starting work if timeframe is less to compile and submit information to complete the project*
Company Information
MANDATORY Information or bids may be disqualified.
Individual Submitting Information:
Name of Company Submitting Information:
Street Address:
City, State & Zip Code:
Contact Phone Number:
Contact Email Address:
Circle Firm Type:
-Corporation
-Partnership
-Individual
-Joint Venture
-Other (Specify)
Circle Typical Work Type:
-General Construction
-HVAC
-Electrical
-Plumbing
-Other (Specify)
ORGANIZATION:
MANDATORY Information or bids may be disqualified.
Please state any certifications (and certifying authority) your organization holds as a registered MBE, DBE, WBE, etc.:
At any time in the past five years, has your organization or an affiliated entity or any of their principals been the subject of an enforcement action or investigation (criminal, civil, or administrative) involving a failure to comply with all applicable immigration laws and regulations?
If your organization is a corporation, answer the following:
-Date of Incorporation:
-State of Incorporation:
-Presidents name:
-Vice President’s name(s):
-Secretary’s name:
-Treasurer’s name:
If your organization is a partnership, answer the following:
-Date of organization:
-Type of partnership (if applicable):
-Name(s) of general partners:
If your organization is individually owned, answer the following:
-Date of organization:
-Name of owner:
If your organization is other than those listed above, describe it and name the principals:
MANDATORY Information or bids may be disqualified.
Have you ever worked for Industrial Contractors Skanska?
How many years has your organization been in business as a Contractor?
How many years has your organization been in business under its present business name?
Under what other or former names has your organization operated?
LICENSING:
MANDATORY Information or bids may be disqualified.
-List all trade categories your organization is legally qualified to perform with Vanderburgh County, Indiana and the City of Evansville, Indiana
-List all registration and/or license numbers your organization has with Vanderburgh County, Indiana and the City of Evansville, Indiana
EXPERIENCE:
MANDATORY Information or bids may be disqualified. An answer of NO does not necessarily disqualify you from bidding but initiates a REVIEW/HOLD process.
List the categories of work that your organization normally performs with its own forces:
Claims and Suits:
-Has your organization ever failed to complete any work awarded to it? (if yes, please attach details)
-Are there any judgements, claims, arbitration proceeding or suits pending or outstanding against your organization or its officers? (if yes, please attach details)
-Has your organization filed any lawsuits or requested arbitration with regard to construction contracts with the last five years? (if yes, please attach details)
-Within the last five years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract? (if yes, please attach details)
MANDATORY Information or bids may be disqualified.
On a separate sheet, list major construction projects your organization has in progress, giving the name of project, owner, architect, contract amount, percent complete and scheduled completion date.
State total worth of work in progress and under contract:
State amount of largest contract amount performed:
On a separate sheet, list the major projects your organization has completed in the past three years, giving the name of the project, owner, architect, contract amount, date of completion and percentage of the cost of the work performed with your own forces
State average annual amount of construction work performed during the past three years:
2015 -
2014 -
2013 -
On a separate sheet, list the construction experience and present commitments of the key individuals of your organization
Employee Resources:
# of Office Employees -
# of Skilled Craftsmen –
# of Shop Labor –
# of Superintendents –
List Union Affiliations -
REFERENCE (1):
MANDATORY Information or bids may be disqualified.
Trade References:
Bank References:
Name of Bonding Company:
Name, Address, Phone, and Email of Agent:
REFERENCE (2):
MANDATORY Information or bids may be disqualified.
Trade References:
Bank References:
Name of Bonding Company:
Name, Address, Phone, and Email of Agent:
REFERENCE (3):
MANDATORY Information or bids may be disqualified.
Trade References:
Bank References:
Name of Bonding Company:
Name, Address, Phone, and Email of Agent:
FINANCIAL:
MANDATORY Information or bids may be disqualified.
Has your company ever filed for bankruptcy?
An answer of YES does not necessarily disqualify you from bidding but initiates a REVIEW/HOLD process.
Please list your organization’s Dun and Bradstreet Number(if applicable):
Please attach your company’s standard insurance certificate.
What is your company’s single project bonding capacity: $
What is your company’s aggregate bonding capacity: $
Please provide letter from Surety providing P&P Bond
Attach a financial statement, preferably audited, including your organization’s latest balance sheet and income statement showing the following items:
-Current Assets
-Net Fixed Assets
-Other Assets
-Current Liabilities
-Other Liabilities
-Name and address of firm preparing attached financial state and date
Attachment of bidder’s financial statement is mandatory. Any bid submitted without said financial
statement as required by statute may thereby be rendered invalid. The financial statement provided hereunder tothe governing body awarding the contract must be specific enough in detail so that said governing body can make a proper determination of the bidder’s capability for completing the project if awarded.
Is the attached financial statement for the identical organization named on page one? If not, explain the relationship and financial responsibility of the organization whose financial statement is provided.
Will the organization whose financial statement is attached act as guarantor of the contract for construction?
PROJECT CONTROLS:
INFORMATIONAL Only – For Review Only.
Does your company routinely use critical path methodology (CPM) scheduling software? (If yes, please identify the type of software routinely utilized?
Do you have full time schedulers internal to your organization?
Do you have an estimating staff internal to your organization?
Do you have experience in developing work plans for current or past clients?
Do you have full time accounting staff internal to your organization?
Do you have experience utilizing a computerized project management system to manage work activities?
QUALITY:
INFORMATIONAL Only – For Review Only. Please note as successful Bidder will be required to provide a Quality Program if you do not have program in place at time of bid with minimum items as noted in Supplementary Instructions to Bidders & Special Conditions - Item 21
Do you have a formal written Quality Program? Please provide a copy of your Quality Program or a description of your program.
Do you have a Quality Control Manual? Provide a copy of the table of contents from your Quality Control Manual.
Do you have a separate QA/QC Department? Please provide organizational chart for department. If no, indicate your company’s QA/QC responsibilities.
Is your company certified ISO 900X? If yes, what is your ISO 900X Certificate #?
Does your company hold any quality certifications? If yes, please provide details.
Are your QA/QC department’s authorities and responsibilities clearly defined in writing?
Does your company train employees in acceptable Quality methods and practices?
Does your company have a Quality Orientation Program for new hires?
Who is responsible for your Quality Program?
SAFETY:
MANDATORY Information required or bids may be disqualified.
Year 2016 To Date:
-Has your company performed work this year?
-Current EMR:
-DART Cases:
-OSHA Recordable Cases:
-Number of fatalities:
-Number of employee hours worked:
Year 2015 To Date:
-Did your company performed work this year?
-Current EMR:
-DART Cases:
-OSHA Recordable Cases:
-Number of fatalities:
-Number of employee hours worked:
Year 2014 To Date:
-Did your company performed work this year?
-Current EMR:
-DART Cases:
-OSHA Recordable Cases:
-Number of fatalities:
-Number of employee hours worked:
Year 2013 To Date:
-Did your company performed work this year?
-Current EMR:
-DART Cases:
-OSHA Recordable Cases:
-Number of fatalities:
-Number of employee hours worked:
BIDDERS will automatically be on a REVIEW/HOLD status and potential for disqualification for the following:
EMR Greater than 1.0
TRIR Greater than 5.0
LTIR Greater than 1.0
DART Greater than 1.7
Any Fatalities in last Two Years
ALL BIDDERS are required to Have a Written Safety Program -
MANDATORY Information or bids may be disqualified. A Written Safety program is required by all subcontractors.
The successful subcontractor shall have a Written Safety Program that addresses the following at a minimum:
Employee Orientation and Training
Addresses Task Specific pertaining to scope of work that company performs
Incident Reporting
Drug Policy
Provide Proper PPE – minimum Hard Hat, Steel Toe Boots, Safety Glasses, Hi-Vis Vests, Gloves
Disciplinary Policy
Corrective Action
Construction Work Plans – provide Sample
Daily Hazard Analysis and Toolbox Talks
The following questions should be answered but will not necessarily disqualify someone from bidding.
Safety Management Systems:
-Does your company have a defined set of goals related to safety?
-Does your company have a defined management leadership and involvement program?
-Does your company have a defined accountability program for observed infractions of your company’s safety and health program?
-Does your company have a crisis management or emergency action plan?
-Does your company have an incident investigation program?
-Does your company have an employee training and development program for workforce, foreman, superintendent and mangers?
-Does your company have a new hire orientation program?
-Does your company have a defined employee performance evaluation process that includes safety performance?
-Does your company have a defined employee involvement plan (i.e., safety committee, feedback program, etc.?)
-Does your company have a defined budget for safety?
-Does your company have a defined incentive and/or recognition program?
-Does your company have an annual self-evaluation program?
-Does your company have defined safety meetings?
-Does your company have an inspection and hazard identification program?
-Does your company have a full-time safety manager on staff? If yes, please upload one of the following, CSP or CHST designations or resume. (Note: this person cannot be a foreman, estimator, project manager, or any other type of administrative personnel.):
- Please note that if you have more than 30 employees on site including subcontractor employees then you are required to provide at least one Full Time Safety Representative for your work.
-Does your company have a defined program for the communication of safety-related items (incidents, accidents, successes, program changes, etc.?):
-Does your company have a policy statement that is endorsed by the company president, owner or executive management?
Safety Program Elements:
-Does your company have a head protection program?
-Does your company have an eye protection program?
-Does your company have a fall protection program?
-Does your company have a hand protection program (i.e., glove policy)?
-Does your company have a program in place for maintaining housekeeping?
-Does your company have a fire prevention and protection program?
-Does your company have a hazard communication program?
-Does your company have a foot protection program?
-Does your company have a soft-tissue injury prevention program in place (material handling)?
-Does your company have an incident and accident reporting program?
-Does your company have a procedure in place to respond to regulatory agency complaints, inspections and citations?
-Does your company have a signs, signals and barricades program?
-Are your employees EVER required to enter or work around trenches or excavations?
-Are your employees EVER required to use electric-powered tools or equipment, OR do your employees work on or around electrical systems/components?
-Does your company perform work in accordance with NFPA 70E when it is required to work on live electrical components?
-Do your employees EVER work with or use hoisting or rigging equipment such as slings, shackles, cranes, hoisting chains, etc.?
-Do your employees EVER operate motor vehicles as part of their required job duties?
-Do your employees use hand or power tools?
-Do your employees EVER use a ladder?
-Do your employees EVER use rolling staging, supported scaffold, suspended scaffolds, mast-climbing scaffolds or other types of scaffolds?
-Do your employees EVER perform welding, cutting, brazing, soldering, or other flame/spark producing activities?
-Does your company perform steel erection?
-Does your company have a hearing conservation program in place to protect against noise levels above 90 decibels?
-Are your employees potentially exposed to dust, silica, fumes, mists, vapors or other respiratory hazards?
-Are your employees required to enter manholes, vaults, pits, shafts, trenches, crawl spaces or other confined spaces?
-Are your employees EVER required to use, store or handle oxygen, acetylene, propane, nitrogen or other compressed gasses?
-Does your company have an environmental protection program?
-Are your employees EVER required to operate or work from boom lifts, scissor lifts or other aerial lifts?
-Do your employees ever work in place where asbestos-containing material could be present?
-Do your employees EVER perform sandblasting operations?
-Are your employees required to attend and/or participate in regularly schedule toolbox talks?
-Are any of your employees required to possess a first-aid or CPR training certification?
-Do your employees ever work in places where lead-based paint or lead-containing materials could be present?
-Does your company have a medical surveillance program for potential exposure to hazardous chemicals, materials or wastes?
-When and if accidents occur, what is the process or procedure to determine the root cause and prevent re-occurrence?
-Does your company perform daily hazard analysis reports on task at hand to ensure employees are aware necessary safety precautions?
-Does your company perform Construction Work Plans to detail out the particulars of specific work activities?
Special Elements:
-Does your company have a “return to work” program for employees who have been injured?
-Does your company have a substance abuse policy that prohibits drug and alcohol use?
-Does your company require candidate employees to submit to a drug and alcohol test before being hired?
-Does your company perform drug and alcohol testing following EVERY employee work-related injury or accident?
-Does your company have a reasonable suspension drug and alcohol testing program?
-Is your company a member of the OSHA VPP program?
-Is your company a member of the SHARP program?
-Is your company a participant of the OSHA Partnership Program
-Has your company received any citations from a regulatory agency during the last three years? If so, please attach detail and explanation
Requested Safety Related Documents – Please attach
-Safety Manual
-OSHA 300A Summary Form
-Insurance EMR Rating letters for the last three years
- An EMR rating greater than 1.0 in the current year will automatically initiate a REVIEW/HOLD process on your bid.
SCOPES OF INTEREST:
Please identify your organizations interest in the following potential bid packages:
- BP 1A Testing
- BP 2B Radio Station Building Demolition
- BP 3A Concrete Work
- BP 3B Precast Concrete (Furnish and Install)
- BP 4A Masonry
- BP 5A Steel (Furnish and Install)
- BP 5B Steel (Furnish Only)
- BP 5C Steel (Erect Only)
- BP 5D Miscellaneous Metals (Furnish and Install)
- BP 5E Miscellaneous Metals(Furnish Only)
- BP 5F Miscellaneous Metals (Erect Only)
- BP 6A General Package
- BP 7A Roofing Package
- BP 7B Sprayed Fireproofing
- BP 8A Curtainwall
- BP 8B Glazing – Interior
- BP 9A Drywall and Acoustical Package
- BP 9B Ceramic Tile
- BP 9C Terrazzo
- BP 9D Carpet and Resilient Flooring
- BP 9E Painting & Wallcovering Package
- BP 13A Radio Frequency Shielding
- BP 14A Vertical Transportation
- BP 21A Fire Protection System
- BP 22A Plumbing Systems
- BP 23A Mechanical/HVAC
- BP 26A Electrical Package
- BP 28A Low Voltage Package
- BP 31A Mass Excavation Package & Site Demolition
- BP 31B Augercast Piling
- BP 32A Landscaping
- BP 32B Site Concrete & Amenities
- BP 32C Hot Mix Asphalt Paving
- BP 33A Underground Utility Package
SIGNATURE (Officer of the Company):
Dated at this ______day of ______2016
Name of Organization:
By:
Title:
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