Subcontractor Prequalification Form

Subcontractor Prequalification Form

Please fill out the following form to prequalify as a subcontractor for our company.
Company Name*
Contact Person*

First NameLast Name
Contact Email*
example@example.com
Contact Phone*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year Business was Established*
States We Do Work In*
Years of Experience*
Please Select One

UnionNon-Union
Previous Name of Company (if applicable)
Contractor's License #*
D&B #*
Qualified Minority Business?

MBEWBEDBE
Area(s) of Expertise*

ConstructionElectricalPlumbingHVACRoofingCarpentryPaintingMasonryLandscapingOther
Certifications (if any)
SAFETY

List your Company's * of Injuries/Illnesses from your OSHA 300 Logs as follows:

	Last Year	1st Prior Year	2nd Prior Year
Experience Modification Rate (EMR)
Total # of Fatalities (From Column F on the OSHA 300 Log)
Total # of OSHA Recordable Incidents. (Total of Columns H, I, and J on the OSHA 300 Log)
Total # of Lost Work Day Incidents. (Column H on the OSHA 300 Log)
Total # of other Recordable cases. (Column J on OSHA 300 Log)
Total # of Annual Man- Hours Worked.

Please check if your Company Implements the following safety controls:

	Yes	No
Has a Written Safety Program
Has an Implemented Drug Screening Policy for all Employees.
Performs Safety Orientation & Training for all Employees
Performs Continuing Safety Education for all Employees

Provide summary of three largest projects presently, under construction.*

Provide the following information regarding your current personnel (the current number of employees in your company):

Please provide the following information for the past three fiscal years:*

What is your backlog as of today ($):*
Your backlog as of December 31st Last Year ($):*
Please provide your company's current financial statements (Your financial statements must be audited by a 3rd party if the proposed contract value is greater than $500,000). In lieu of providing financial statements, Genesis Homes NE LLC will accept a Letter of Bond ability from your surety company (NOT your surety agent) on it's letterhead. Please ensure that the letter includes your single job and then aggregate parameters.*

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Please provide answers to the following questions:*

	Yes	No
Are there any judgments, claims, arbitrations, proceedings or suite pending/outstanding against your company or it's officers or it's principals?
Has your company ever filed bankruptcy?
Has your firm filed any lawsuits or requested arbitration or mediation with refard to construction contracts within the last three (3) years?
Has your company or any other organization, with which of the officers or partners were involved during the past three (3) years, ever failed to complete any work awarded?

If you checked YES for any of the questions provided above, please further explain below.
Submit a listing of all litigation or formal arbitration to which your organization has been a party involving amounts in excess of $10,000 for the past five (5) years including any unsettled litigation or arbitration.

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Insurance & Bonding
Insurance Coverage (If any):
Can you provide a Performance Bond?

YesNo
Bond Rating
Bond Capacity
Single Project
Aggregation
Bond Cost(% or $/1000)
Name of Bonding Company
Point of Contact
Phone Number
Last Type of Bond Issued
Date
Amount ($)
REFERENCES

Please provide three (3) client references*

Please provide financial references*

	Name of Bank	Point of Contact	Phone Number
1
2

Please provide three (3) supplier references*

I hereby Certify that the information submitted herein, including any attachments I have provided are true and sufficiently complete so as not to be misleading.
Completed by:

First NameLast Name
Signature

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This documentation will be used by Genesis Homes NE LLC to pre-qualify subcontractors. This document should not be construed as a commitment or a request to perform any work.
Should be Empty:

SAFETY