Initial Prequalification Form

	Annual Sales
2023 (anticipated)
2022
2021
2020

	Employees
Shop
Field
Office


Bonding Company:
A.M. Best Rating:
Bonding Rate %:
Bonding Capacity (Single Project):
Bonding Capacity (Total):

	EMR
2022
2021
2020

	TRIR
2022
2021
2020

	DART
2022
2021
2020

	OSHA Citations
2022
2021
2020

	Current Workload
Dollars
Manpower (# of Workers)

	Largest Project
Project Name:
Volume $:
Time Frame (months):

Please enter any applicable state-issued licenses below:

	State	License Number	Class/Type	Expiration
License 1
License 2
License 3
License 4
License 5

Click to view sample insurance requirements

TG Gallagher, Inc. Insurance Requirements

COI Sample

Has your company reviewed the attached insurance requirements?*

YesNo

Does your company currently meet or exceed the policy limits within?*

YesNo

Does your company have Professional Liability Insurance?*

YesNo

If yes, please identify the following related to your Professional Liability Policy:

	Professional Liability
Policy Limit Per Occurrence
General Aggregate
Deductible

Does your company have Pollution Liability Insurance?*

YesNo

If yes, please identify the following related to your Pollution Liability Policy:

	Pollution Liability
Policy Limit Per Occurrence
General Aggregate
Deductible

Click to view sample subcontract agreement

TG Gallagher, Inc. Subcontract Agreement

Has your company reviewed the attached Subcontract Agreement?*

YesNo

Does your company agree to the language in the attached Subcontract Agreement with no modifications?*

YesNo

Click to view sample lien waviers

Lien Waiver Example

Final Lien Waiver Example

Has your company reviewed the sample Lien Waivers and agrees to the terms?

YesNo

Please complete the following bank / financial information:*

	Current
Name of Bank:
DUNS Number:

The following documents are required to complete your Prequalification Application with TG Gallagher:

2 years of audited or professionally prepared financial statements-balance sheet, income statement & cash flow statement.
A current bonding capacity letter
Worker's compensation modification rate verification letter from your current insurance agent.

SUBMISSIONS ARE SECURE AND CONFIDENTIAL

If you prefer not to upload your documents, please mail them to our Waltham office

Please list contact information for three major suppliers to your company:*

Supplier 1

Supplier 2

Supplier 3

Please list contact information for three Subcontractors that your company worked for within the past 2 years:*

Company 1

Company 2

Company 3

We hereby certify we have answered the above questions as accurate and complete to the best of our ability. We also affirm that all documents submitted as true and accurate.*

Initial Pre-Qualification Form

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