Subcontractor Pre-Qualification Form

Insurance Information

(See Sample for Insurance Requirements)
Certificate of Insurance will be required as proof of insurability.
Name of Insurance Company
References

Please provide at least 3 job references including project name, location and general contractor
Reference #1
Reference #2
Reference #3
Main Bid Contact (Please include full name, cell phone # and email)
Locations
Main Location

	Current Year	2012	2011	2010	2009	2008
2. Total man-hours worked including overtime (in 000’s)
3. Total # of OSHA recordable cases
4. # of lost workdays
5. # of lost workdays
6. # of cases with job transfer or restriction
7. # of days of restricted work activity
8. # of fatalities

	Monthly	Annually	Not at this level
18. Accidents totaled for all company
19. Accidents totaled by project
20. Accidents subtotaled by foreman
21. Costs totaled for all company
22. Costs totaled by project
23. Costs subtotaled by foreman

	Yes	No	N/A
27. Eye/face protection
28. Head protection
29. Hearing protection
30. Respiratory protection
31. Personal fall protection device
32. Foot protection
33. Hand protection
34. Scaffolding
35. Perimeter guarding
36. Housekeeping
37. Fire protection
38. First aid procedures
39. Emergency response
40. Hazard communication as per 1926.59
41. Trenching and excavation
42. Signs, barricades and flagging
43. Substance abuse – alcohol & drug screening
44. Lock out/tag procedures
45. Electrical safety
46. Rigging and crane safety
47. Accident reporting
48. Competent person requirements

	Yes	No	N/A
50. Safe work practices
51. Job hazard analysis
52. New hire safety orientation
53. First aid
54. Emergency response procedures
55. Accident investigation procedures and techniques
56. Chemical hazard communication
57. Fire protection and fire prevention
58. Conducting tool box safety meetings
59. OSHA standards applicable to your company operations