Date of Submission: 

General

Company Name:

Address:

Contact Info:

Additional Contact Info:

Type of Business:CorporationPartnershipJoint VentureIndividualOther

If "Other" please specify:

Labor Relations:UnionNon-Union

Please list the trade(s) your company performs:

Please check which industries where your company has worked in the past 5 years.

ResidentialHigh-rise buildingMid-rise BuildingSports Stadium

University/Higher EducationHospitalFederal BuildingsIndustrial

Schools K-12Apartment ComplexOther

If Other:

Size of work performed by your company:

under $100,000$100,000-$200,000$200,000-$500,000$500,000-$1,000,000

$1,000,000-$3,000,000$3,000,000-$6,000,000$6,000,000-$9,000,000

$9,000,000-$12,000,000$12,000,000-$15,000,000$15,000,000-$20,000,000

over $20,000,000

How many years has your company been in business as a contractor?

Number of employees:

BONDING

Current bonding capacity of company: Aggregate: Single Project:

INSURANCE

PLEASE PROVIDE A CERTIFICATE/LETTER FROM YOUR INSURANCE PROVIDER VERIFYING ALL LIMITS, EMR AND PROJECT REQUIREMENTS.

Experience Modification Rating (EMR) for the last three years:

SAFETY

PLEASE PROVIDE COPIES OF OSHA 300A LOGS FOR THE LAST THREE COMPLETE YEARS.

Does your company have a written Safety Program?YesNo

(If "yes", please provide a copy of your Safety Program)

Does your company have a disciplinary program for safety violations?YesNo

Does your company have a Substance Abuse Program?YesNo

Please list the type of safety training provided for all employees:

Does your company have a safety officer or qualified person within your company? YesNo

Please list their qualifications:

Has your company had any OSHA citations within the last three years?YesNo

If "yes", please provide details:

Has your company had any jobsite fatalities in the last three years?YesNo

If "yes", please provide details:

Please remember to send in the following:

• Insurance EMR verification

• OSHA 300A logs for the last 3 complete years

• Company Safety Program

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