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Date:

COMPANY:

Company Name:

Address:

Phone Number:….Fax Number:

Contact Name:

Contact Email:

Type of company:

Date Formed:

Federal tax ID#:

LABOR:

Does the company have any union agreements?  Yes No

MBE/WBE/SBE/DBE CERTIFICATION:

Is your firm certified?  Yes No

If yes, please check all that apply: MBE WBE SBE DBE DVBE LSDBE OTHER

Certifying Agency (s):…………………………………………Certification Number (s)


BONDING CAPACITY:

Are you able to bond projects?:  Yes No

Bonding Rate:

Single project limit:…………………………………………… Aggregate limit:

Bonding company address:…………………………………. Agent name:

Agent phone number:

SAFETY:

Experience Modification Rate (EMR) for the past three years:

Current Year:

1st prior year:

2nd prior year:

Does the company have a written safety program and/or policies? Yes No
Does the company have a written drug policy? Yes No
Does the company employ a full-time safety professional? Yes No
In the last three years has the firm been cited for any serious (defined by OSHA) Violations? Yes No

INSURANCE:

Acknowledge you have the following minimum coverage:  Yes No

Workers Compensation Insurance: Statutory Coverage in state where work is being done.
100,000 each accident
100,000 disease each employee
500,000 disease policy limit

General Liability:
1,000,000 each occurrence.
2,000,000 aggregate.
1,000,000 products and completed operations.

Auto:
1,000,000 any auto, hired and non owned.

Umbrella or Excess Liability:
1,000,000 each occurrence
1,000,000 aggregate

Insurance company address:

Agent Name:

Agent phone: