I. General Information  
Business Name
 		Address
City
 		State
Zip
 		E-mail
Telephone
 		Fax
Contact name and title
 Is your operation union or non-union or both?
Union Non-Union
   
   
II. Organization  
Business type:
Corp Partnership LLC  
  		  Date founded
If other Business type, please specify:
State of formation
   
III. Licensing Information  
Please provide all trade and professional licenses, if any, required for you to perform your services.
Type of License/Name of Licensee:
State:
License Number:
   
IV. Work Experience  
Please attach a list of the major projects your firm has completed in the last three years showing the (1) project name, (2) location, (3) owner, (4) architect/engineer, (5) general contractor, (6) contract amount and the (7) completion date and contact person with telephone number.
What is your average job size
 What was your largest job ever completed? (project name and contract amount) In what year?
What is your backlog?
  
List 3 major vendors, including contact name and phone number.

Vendor I:II
 Phone Number:
Vendor II:I
 Phone Number:
Vendor III:
 Phone Number:
Are there any judgements, claims, arbitration proceedings, or suits pending/out-standing against your firm or its officers or principals? Yes No
If yes, please provide a complete explanation.
Has your firm filed any lawsuits or requested arbitration or mediation with regard to construction contracts within the last three years? Yes No
If yes, please provide a complete explanation.
Has your firm or any other organization with which your officers or owners were involved during the past three years, ever been in bankruptcy or a voluntary or involuntary reorganization? Yes No
If yes, please provide a complete explanation.
V. References
Banking reference
Company name
 Address
Contact name
 Phone
Bonding reference
Company name
 Address
Bonding Agent
 Phone
Bonding capacity

single limit

total program bonding limit
 Bond rate
VI. Safety and Health
Please list your firm’s Workers compensation interstate experience modification rate for the most recent one full year (if available, please attach a copy of your insurance agent’s verification letter).
Year
 Experience Modification Rating
Do you have a full-time safety representative?
Yes No
Has your firm had any OSHA fines or jobsite fatalities within the last three years? Yes No
If yes, please provide a complete explanation.
VII. Additional Information
Please attach any additional information you feel will help us determine your firm’s qualifications and expertise, including owner or general contractor references, etc.
VIII. Insurance
Carrier Name
 Phone
Please indicate your limits of:  

Commercial General Liability

 Automobile Liability
 Personal & Adv. Injury
Each Occurrence
 Excess Liability / Umbrella
 Worker's Comp

I hereby certify that the above information is accurate, correct and true. (Please check if yes)

Completed by:
Name:
 Title:
Date: