New Sub Application

Subcontract Pre-Qualification Worksheet

Please complete the enclosed subcontractor pre-qualification questionnaire to help us better understand your companies’ operations, capabilities, safety records, and experience. Upon completion please forward a copy of your W9, Certificate of Insurance, and all required attachments to our Administrative Department via E-Mail or Fax. (E-Mail: or Fax: 972.501.9779)

COMPANY INFORMATION:

Company Name: ______

Address: ______

Phone: Fax: ______

Estimating Contact: ______

Estimating E-mail Address:

Project Management Contact(s): ______

Principal(s): ______

CSI Code/Trade: ______

What size projects do you prefer? ______

How long has your firm been in business under its present name? ______

Federal Employer ID #: ______Contractors License Number: ______

How many total employees do you have? How many are field employees? ______

Geographic range of service: ______

Are you a Minority or Women-Owned Business? ______If yes, provide certification number______

Has your firm gone through an ownership change in the last twelve (12) months? ______

If yes, please explain: ______

PERFORMANCE INFORMATION:

Has an owner or general contractor terminated your contract for cause in the last five (5) years? ______

If yes, please explain: ______

Has your company failed to complete any construction contracts in the last five (5) years? ______

If yes, please explain: ______

Provide 5 supplier or financial trade references as an attachment to this form, including company name, address, contact name, and phone and fax number:

Provide the firm name, contact name and phone number of the general contractor along with the contract amount for 3 of your current projects:

Project 1 Project 2 Project 3

Project Name ______

Contract Value ($) ______

GC Firm Name ______

GC Contact Name ______

GC Phone # ______

Surety Broker/Agent Phone #: ______

Bond Capacity: Per Job $______Aggregate $ ______Bond Rate (per thousand):______

Insurance Information & Qualifications –

Please attach the following information:

 Resumes of key personnel or outline of experience in this trade.

 Reference list (Clients, General Contractors, Suppliers).

 Current certificate of insurance detailing the following minimum coverage:

 Workman’s Compensation: As required by law.

 General Liability: $1,000,000 each occurrence; $2,000,000 aggregate combined single limit of

liability including projects and completed operations.

Automobile Liability: $500,000 combined single limit of liability including hired and non-owned

coverage.

Please attach a copy of your Certificate of Insurance listing Highland Builders, Inc., as the Certificate Holder and as additionally insured.

SAFETY INFORMATION:

Provide your EMR rating for the last three (3) years: 2014 2013 2012

______

In the last five (5) years, has your company been cited by OSHA for a “serious” or “willful” violation?______

If yes, please explain: ______

Provide a copy of your current OSHA 300 log as an attachment to this form.

Does your company have a written safety program in place? ______

If awarded contracted work a safety program manual must be provided to HBI.

Does your company have a training program for all employees in place? ______

I certify that the information provided in this application and the attached material is true and sufficiently complete so as not to be misleading.

Signature: Date: ______

Printed Name: ______