Contractor Pre-Qualification/Safety Form

Contractor Pre-Qualification/Safety Form
All information within this Pre-Qualification Form and attachments will be held strictly confidential. First Companies and its clients (project owners) may reject the bid proposal if the contractor qualifications and/or safety record are found to be unacceptable. Incomplete or inaccurate information may be grounds for dismissal of any and all bid proposals.
GENERAL COMPANY INFO AND HISTORY
Organization Name*
Address Line 1*
Address Line 2
City*
State*
Zip*
Phone*
Format: (000) 000-0000.
Fax
Primary Contact Name*
Phone*
Format: (000) 000-0000.
Title*
Email*
example@example.com
Bidding Contact Name*
Phone*
Format: (000) 000-0000.
Title*
Email*
example@example.com
Invoice Contact Name*
Phone*
Format: (000) 000-0000.
Title:*
Email*
example@example.com
ProcoreOther:
Scopes of work performed (CSI Divisions):*
Percent of work performed by own trade forces (not subcontracted):*
Number of years the company has been in business as a contractor:*
Number of years the company has been in business under its current name:*
Other names the organization has operated/done business as:
C Corporation:S CorporationPartnership:Joint Venture:LLCIndividual:MBE/WBE:Other:
Total number of current FIELD STAFF employed by organization:*
Total number of current OFFICE STAFF employed by organization:*
If your organization is a Corporation, please complete the following fields:
President's Name:
Vice President's Name:
Other Executive Team Member(s)
YESNO
If yes, please list previous completed projects.
List your workers' compensation experience modifier for the last three (3) years:
EMR Year (i.e. 2019):   *  EMR Rating:   *
EMR Year (i.e. 2020):   *  EMR Rating:   *
EMR Year (i.e. 2021):   *   EMR Rating:   *
YESNO
Number of last year’s OSHA recordable injuries & illnesses from the OSHA 300 Form:*
YESNO
YESNO
If yes, how are they documented? (Must be available for review.)*
LEGAL - Claims and Suites

NOTE: If you answer 'YES' to any of the below questions, please attach details.
YESNO
YESNO
YESNO
YESNO
If you answer 'YES' to any of the questions above, please attach any file(s) providing additional details.

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Workload/References
What is the total dollar value of current work in progress under contract?*
List the average annual amount of work performed by your organization over the last five (5) years?*
REFERENCES:

List three (3) CM/GC or suppliers for reference (company, address, contact, phone)
1. Company*
Contact*
Address*
Phone*
Format: (000) 000-0000.
2. Company*
Contact*
Address*
Phone*
Format: (000) 000-0000.
3. Company*
Contact*
Address*
Phone*
Format: (000) 000-0000.
FINANCIALS
BANK REFERENCE INFORMATION:
Bank Name*
Contact*
Phone Number*
INSURANCE CARRIER REFERENCE INFORMATION:
Insurance Carrier Name*
Contact*
Phone Number*
Provide a copy of existing certificate of insurance with expiration date and limits.*

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Submit complete audited or reviewed financial statement for the organization for the previous fiscal year. Include a Balance Sheet and Income Statement. This information will be held strictly confidential. (Label as FINANCIAL STATEMENT.)*

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CERTIFICATION

By completing the section below, you hereby certify the information provided in this pre-qualification form and the attached statements to be true in their entirety. You also certify that the information is sufficiently complete so as not to be misleading.
Organization Name:*
Contact:*
Title:*
Date:*

MonthDayYear
Date
Signature:*

Clear
Thank you for your interest in working with First Companies!

Our team is actively reviewing your submission and will be in contact as needed.
Should be Empty:

Contractor Pre-Qualification/Safety Form

GENERAL COMPANY INFO AND HISTORY

LEGAL - Claims and Suites

Workload/References

FINANCIALS

CERTIFICATION