Address *

City-State-ZIP Code *

Phone *

Fax *

Person submitting this Pre-qualification Statement *

Phone *

Cell Phone *

Email Address *

Website Address *

Is Your Company *

MBE WBE DBE

MBE/WBE/DBE Certified by: *

Trades
[Please fill-in the trade(s) that your Company is interested in bidding ] *

Year Company Started: *

Type of Company:*

Corporation

Partnership

Proprietorship

Sub. S. Corp

State of Incorporation: *

Year of Incorporation: *

Contractor’s License Number: *

State *

Expiration *

State Sales Tax Registration Number*

State Unemployment Insurance Number: *

Federal ID Number: *

Under what other names has your Company operated *

How many people does your Company presently employ: *

Number at Home Office *

Number Field Supervisory *

Trades people *

Has your Company or any of its principals ever petitioned for bankruptcy, failed in business, defaulted or been terminated on a contract awarded to you *

Yes No

If yes, please explain:

Have any of the Owners, officers or major stockholders of your Company ever been indicted or convicted of any felony *

Yes No

If yes, please explain:

Has your Company or any Owners, officers or major stockholders ever been suspended, disbarred or otherwise precluded from pursuing public work or ever been found to be non-responsive by a public agency *

Yes No

If yes, please explain:

Has your Company ever had a claim made against it for improper, delayed, defective or non-compliant work or failure to meet warranty obligations

Yes No *

If yes, please explain:

Is your Company or any of its owners, officers or major shareholders currently involved in any arbitration or litigation *

Yes No

If yes, please explain:

Does you Company have any outstanding judgments or claims against it *

Yes No

If yes, please explain:

Please list any litigation brought against your Company in the past five (5) years asserting that you failed to make payments to anyone. *

List the geographical areas in which you work: *

List Unions which you have agreements with: (Include Local Number, Union Name and Agreement Expiration Date(s) *

Indicate the size of project you are most competitive in performing: *

Under $100,000

$100,000 -$200,000

$200,000 -$500,000

$500,000 -$1,000,000

$1,000,000 -$3,000,000

What percentage of the Company’s work is normally subcontracted *

What trades do you normally subcontract *

What is the largest contract your Company has completed

Amount: *

Year *

Project name and scope: *

What is the largest dollar volume job you expect to do during this year

Amount: *

Project name and scope: *

What is your expected annual volume this year:

Amount: *

Number of Projects *

What was the average annual volume of work performed over the past 4 years:

Year/Volume *

Year/Volume *

Year/Volume *

Year/Volume *

MBE/WBE Participation in work which you subcontract (average participation for last 3 years)

MBE *

WBE % *

Minority/Female workforce participation (average percentage utilization for last 3 years)

Minority *

Female *

List your current major projects (Include contact people and phone numbers)

Name of project  *

Address *

Owner *

Architect *

General contractor *

Name of project  *

Address *

Owner *

Architect *

General contractor *

Name of project  *

Address *

Owner *

Architect *

General contractor *

List your recently completed major projects (Include contact people and phone numbers):

Name of project  *

Address *

Owner *

Architect *

General contractor *

Name of project *

Address *

Owner *

Architect *

General contractor *

Name of project *

Address *

Owner *

Architect *

General contractor *

Name of your Bank: *

Address: *

Phone: *

Contact Person : *

Amount of line of credit: *

Amount Available: *

Expiration date: *

UCC Filing *

Yes No

How is credit secured: *

What is Company’s Dunn & Bradstreet Number : *

D&B Rating: *

Pay Record: *

Date of Rating: *

Bonding Company: *

Name of Surety: *

Key Contact Person/Phone: *

Bonding Capacity:

Per Job *

Aggregate:*

Date of Last Bond Amount : *

Bond Rate: *

List three of your major suppliers:

Name *

Address *

Contact *

Phone Number *

Name *

Address *

Contact *

Phone Number *

Name *

Address *

Contact *

Phone Number *

List three contractors that you do business with:

Name *

Address *

Contact *

Phone Number *

Name *

Address *

Contact *

Phone Number *

Name *

Address *

Contact *

Phone Number *

List local or national accredited training programs in which you participate (craft or management training): *

List key office personnel and field supervisors: *

Name - Position - Years of Experience - Previous Employer *

List any subsidiaries and affiliates of your Company: *

SAFETY

Who is responsible for coordinating your Company’s Safety Program

Name *

Title *

Phone Number *

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

Current *

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 Substance abuse policy *

Yes No

Indicate below your safety training for employees: *

Employee Initiation Safety Training *

Yes No

Supervisors/Managers *

Yes No

Tool Box Meetings *

Yes No

How many full-time safety professionals does your Company employ *

Does this person do safety inspections on all of your projects  *

Yes No

Do you have a return to work/light duty program *

Yes No

If yes, please describe:

Does your Company have a disciplinary program in place for safety violations *

Yes No

Does your Company review the safety management systems of your sub-subcontractors *

Yes No

Does your Company conduct accident/incident investigations *

Yes No

What percentage of supervisory employees have completed an OSHA 30 Hour Training Program *

List your OSHA Recordable Incident Rate over the last five years

Year / Recordable Rate / Lost Time Rate *

In the past five years has your Company been cited for any serious (as defined by OSHA) OSHA violation  *

Yes No

If yes, please describe: *

INSURANCE (Please answer ALL Insurance questions below, or email a copy of your most recent certificates to Info@Nationwide-Fence.com)

Commercial General Liability

Insurance Carrier: *

Expiration Date: *

Limits of Insurance:

Each Occurrence Limit *

General Aggregate *

Completed Opps Agg. *

Personal Injury Limit *

Amount of Deductible or SIR *

General aggregate apply on a per project basis *

Yes No

Excess Liability

Insurance Carrier: *

Expiration Date: *

Limits of Insurance:

Each Occurrence Limit *

General Aggregate *

Worker’s Compensation and Employer’s Liability

Insurance Carrier: *

Expiration Date: *

Limits of Insurance:

Each Accident *

Amount of Deductible or SIR *

Business Auto Liability

Insurance Carrier: *

Expiration Date: *

Limits of Insurance:

Combined Single Limit *

Property Damage *

B.I. per Person *

B.I. per Accident *

Professional Liability Insurance

Do you have professional liability insurance *

Yes No

Insurance Carrier: *

Expiration Date: *

Limits of Insurance: *