HC CONSTRUCTORS | PRE QUAL FORM
PRE QUALIFICATION FORM
Contractor
Address
Federal ID Number
Telephone
Format: (000) 000-0000.
Fax
Years in Business
If incorporated, what year
State
Name of bonding Company
Address
Contact
Phone
Format: (000) 000-0000.
Total Bonding Amount
List your organization's Experience Modification Rate (EMR) for the past 3 years:
2022
2021
2022
Does your organization have a written Company Safety Program? (Y/N)
If requested will a copy be available? (Y/N)
Do you hold site safety meetings for field supervisors?
If so, how often?
Weekly
Bi-Weekly
Monthly
Less often, as needed
Do you hold craft "toolbox" safety meetings?
If so, how often?
Weekly
Bi-Weekly
Monthly
Less often, as needed
Do you conduct project safety inspections?
If yes, who conducts this inspection (title)?
How often?
Do you have a program for newly hired or promoted foreman?
If yes, does it include instruction on the following:
Safe work practices
Safety supervision
Toolbox meetings
Emergency procedures
First Aid procedures
Accident investigation
Fire protection & prevention
New work orientation
Do you have a program for newly hired employees?
Who does the training?
Using last year's OSHA no. 200 log fill in:
Fatalities (Number):
Fatalities (Incident Rate)
Injuries/Lost Workdays (Number)
Injuries/Lost Workdays (Incident Rate)
Injuries Involving Days Away (Number)
Injuries Involving Days Away (Incident Rate)
Days Away from Work (Number)
Days Away from Work (Incident Rate)
Days of Restricted Work Activity (Number)
Days of Restricted Work Activity (Incident Rate)
Injuries Without Lost Workdays (Number)
Injuries Without Lost Workdays (Incident Rate)
List 2 significant projects completed in the last five years that are similar to the pending project:
Project 1:
Project Name
Address
Contact
Telephone
Format: (000) 000-0000.
Fax
Your Contract Amount $
Labor Value $
Project Scheduled Start Date
/
Month
/
Day
Year
Date
Scheduled Completion Date
/
Month
/
Day
Year
Date
Actual Completion Date
/
Month
/
Day
Year
Date
Your Average Size Work Force
List 2 significant projects completed in the last five years that are similar to the pending project:
Project 2:
Project Name
Address
Contact
Telephone
Format: (000) 000-0000.
Fax
Your Contract Amount $
Labor Walue $
Project Scheduled Start Date
/
Month
/
Day
Year
Date
Scheduled Completion Date
/
Month
/
Day
Year
Date
Actual Completion Date
/
Month
/
Day
Year
Date
Your Average Size Work Force
References
Document 3 references below.
Reference 1
Contact
Company
Telephone
Format: (000) 000-0000.
Fax
Email
example@example.com
Last Project worked with Reference 1
Size of last project worked with Reference 1
Reference 2
Contact
Company
Telephone
Format: (000) 000-0000.
Fax
Email
example@example.com
Last Project worked with Reference 2
Size of last project worked with Reference 2
Reference 3
Contact
Company
Telephone
Format: (000) 000-0000.
Fax
Email
example@example.com
Last project worked with Reference 3
Size of last project worked with Reference 3
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