Subcontractor Prequalification Form

conceptcsi will use this documentation to pre-qualify contractors. If you would like to be on our bid list, it is essential that you return the documentation as requested. This document should not be construed to constitute a commitment, or a request to perform any work.

Step 1 of 2

Name

This field is for validation purposes and should be left unchanged.

Application

All subcontractors are required to complete this questionnaire. The contents will be used solely to determine your firm’s qualification to perform work for conceptcsi. This form must be filled out completely; missing information may result in disqualification of consideration.

Application Date(Required)

Date of Prequal Expiration

Background

Company Name(Required)

Type of Company(Required)

Type of Work/Trade Performed(Required)

Tax ID Number(Required)

Street Address(Required)

City/State/Zip(Required)

Phone Number(Required)

Fax Number

Principal Contact(Required)

Email Address(Required)

Year Business was Established(Required)

States We Do Work In(Required)

Union / Non-Union(Required)

Union

Non-Union

Open Shop

Previous Name of Company (if applicable)

Contractor's License #

D&B #

Qualified Minority Business?

Check all that apply.

MBE

WBE

DBE

Safety

List your Company’s # of Injuries/Illnesses from your OSHA 300 Logs for the last three years.

Experience Modification Rate (EMR)

Last Year(Required)

1st Prior Year(Required)

2nd Prior Year(Required)

Total # of Fatalities (Column G, OSHA 300 Log)

Last Year(Required)

1st Prior Year(Required)

2nd Prior Year(Required)

Total # of OSHA Recordable Incidents (Columns H, I, J)

Last Year(Required)

1st Prior Year(Required)

2nd Prior Year(Required)

Total # of Lost Work Day Incidents (Column H)

Last Year(Required)

1st Prior Year(Required)

2nd Prior Year(Required)

Total # of Other Recordable Cases (Column J)

Last Year(Required)

1st Prior Year(Required)

2nd Prior Year(Required)

Total # of Annual Man-Hours Worked

Last Year(Required)

1st Prior Year(Required)

2nd Prior Year(Required)

Has a Written Safety Program(Required)

Yes

Has an Implemented Drug Screening Policy for all Employees(Required)

Yes

Performs Safety Orientation & Training for all Employees(Required)

Yes

Performs Continuing Safety Education for all Employees(Required)

Yes

Safety/Health Professional Contact

Name(Required)

Title(Required)

Phone Number(Required)

Email Address(Required)

Schedule

Three Largest Projects Presently Under Construction(Required)

Project Description

Location

Start/Completion

Contract Amount ($)

Present Personnel – Current Number of Employees(Required)

Position

Full-Time

Part-Time

Contract

Temp

Financial History

Financial Information – Past Three Fiscal Years(Required)

Fiscal Year

Gross Revenue ($)

# of Projects Completed

Largest Single Project ($)

Enter one row per year: 2nd Prior Year, 1st Prior Year, Last Year.

Backlog as of Today ($)(Required)

Are there any judgments, claims, arbitrations, proceedings or suits pending/outstanding against your firm or its officers or principals?(Required)

Yes

Has your firm ever filed bankruptcy?(Required)

Yes

Has your firm filed any lawsuits or requested arbitration or mediation with regard to construction contracts within the last three (3) years?(Required)

Yes

Has your firm, or any other organization with which the officers or partners were involved during the past three (3) years, ever failed to complete any work awarded?(Required)

Yes

Explanation for any 'Yes' answers above(Required)

Litigation / Formal Arbitration Listing(Required)

List all litigation or formal arbitration to which your organization has been a party involving amounts in excess of $10,000 for the past five years, including any unsettled litigation or arbitration. Write ‘None’ if not applicable.

Insurance & Bonding

Please read attached Exhibit in its entirety.

Does your company currently maintain insurance that meets the insurance requirements?(Required)

Yes

Can you provide a Performance Bond?(Required)

Yes

Bond Rating

Bonding Capacity – Single Project ($)

Bonding Capacity – Aggregate ($)

Bond Cost (% or $/1000)

Name of Bonding Company

Bonding Company Contact

Bonding Company Phone Number

Last Type of Bond Issued

Date of Last Bond Issued

Amount of Last Bond ($)

References

The below references may be contacted by conceptcsi for verification purposes.

Client References (provide three)(Required)

Company Name

Contact

Phone Number

Financial References (provide two)(Required)

Name of Bank

Contact

Phone Number

Supplier References (provide three)(Required)

Company Name

Contact

Phone Number

Certification

Certification(Required)

I hereby certify that the information submitted herein, including any attachments, is true and sufficiently complete so as not to be misleading.

Completed By(Required)

Title(Required)

Date Completed(Required)