Subcontractor Pre-Qualification Form

Company Name

Contact Person *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Federal ID#

Email *

Website / URL

Type of work qualified to perform: (masonry, steel, etc.)

Year Business Started

Number of Employees

Has Company or any of its Owners Declared Bankruptcy in last 5 years?

Yes
No

Is Company Bondable?

Yes
No

If Your Company is NOT Bondable what is your Single Project Limit in dollars?

Have you ever failed to complete a project

Yes
No

Explain why the project(s) wasn't completed

Have you had a contract terminated due to performance?

Yes
No

Explain why you had a contract terminated due to performance

What is you r current Worker’s Compensation Experience Modification Rating (EMR)

Number of jobs run at a time

Annual Volume ($)

Largest Job ($)

Average Job ($)

Smallest Job ($)

Current Contract Backlog

Union / Signatory

Yes
No
Subcontractor
Vendor/Supplier

Business Type

Specify

Owner/Officers Name & Title

Years with Company

Owner/Officers Name & Title

Years with Company

Owner/Officers Name & Title

Years with Company

Legal Information

Are there any judgments, claims, arbitration proceedings, or suits pe nding/out - standing against your firm or its officer or principals?

Yes
No

Please provide a complete explanation

Has your company filed any lawsuits or requested arbitration or mediation with regard to construction? contracts within the last three (3) years?

Yes
No

Please provide a complete explanation

References

Banking

Name & Branch

Since?

City, State, Zip

Contact Person

First

Last

Bonding

Bonding Company

Since?

Surety Broker/Agent

Since?

Contact Person

First

Last

Phone

Bonding Capacity – Per Project $

Aggregate $

Last Bond Issued – Date / Amount $ / Rate %

Please attach a formal letter from your bonding company

Insurance

General Liability Carrier

Since?

Insurance Broker/Agent

Since?

Contact Person

First

Last

Phone

What is your limit to Liability insurance?

Suppliers

Supplier Name & Location

Contact Person

First

Last

Phone

Supplier Name & Location

Contact Person

First

Last

Phone

Supplier Name & Location

Contact Person

First

Last

Phone

3 References (Owner, Architects, and at least 2 General Contractors for work completed within the last 2 years):

Project

Company

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Contract $

Project

Company

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Contract $

Project

Company

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Contract $

Financial Information

Financial Reference: Please attach a copy of the following:

Your most recent full fiscal - year-ending Balance Sheet, Income Statement and Cash Flow.

Your most recent quarterly year-to-date Balance Sheet, Income Statement and Cash Flow.

Has your company or any other organization with which your officers were involved during the past three (3) y ears, ever been in bankruptcy or a voluntary reorganization?

Yes
No

Please explain

Revenue

Annual Volume: What was the annual volume of work completed in the last three years as well as next year’s forecast (Forecast Volume )

Experience

Has your company had experience with LEED project

Yes
No

Safety

Does your firm have a written safety plan?

Yes
No

Has your firm had any OSHA citations, fines, or jobsite fatalities within the most recent three (3) years?

Yes
No

If yes, please describe in detail what occurred and what steps were taken by the company to prevent from happening in the future.

OSHA Incident Rate: Please list your firms OSHA incident rate for the most recent three (3) years

YR. / Rate

Additional Information

Please attach any additional information you feel will help us determine your company’s qualif ications and expertise.

I hereby certify that the above information is accurate, correct and true.

Name *

First

Last

Date / Time

Date

Time

NOTE: WOJCIK BUILDERS, INC. REQUIRES AN INSURANCE CERTIFICATE ON FILE INDICATING AUTO, GENERAL LIABILITY AND WORKER’S COMPENSATION INSURANCE AND EXPIRATION DATES; PLEASE MAIL OR FAX TO: Wojcik Builders, Inc., 7579 First Place, Oakwood Village, OH 44146 Fax: (440) 786-1576 NO SUBCONTRACTOR WILL BE PRE-QUALIFIELD WITHOUT INSURANCE OF FILE.