SUBCONTRACTOR PRE-QUALIFICATION FORMPlease enable JavaScript in your browser to complete this form.Company Name *LayoutApplicant Name *PhoneAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeGENERAL OVERVIEWHas your company ever worked for CopperRock Construction as Subcontractor? *YESNOPlease list which project(s) you have worked onHow many years has your company been in business? *Has your company operated under or done business as any other names? *YESNOPlease list the other names your company has operated or done business asOrganization Type *S CORPORATIONC CORPORATIONPARTNERSHIPJOINT VENTURELIMITED LIABILITY COMPANYINDIVIDUALOTHERLayout# of Field Employees# of Office EmployeesExecutive TeamPlease list the names of your company's top three executive team leaders & their respective titlesLayoutExecutive Name #1 *Job TitleLayout (copy)Executive Name #2 *Job TitleLayout (copy) (copy)Executive Name #3 *Job TitleLayoutWhat divisions of work does your company perform? *Within those divisions, what scopes in particular? *LayoutAverage volume of work over the past (3) yearsDollar value of work currently under contract:What percent of work does your company subcontract? *LayoutWhat is the largest contract your company has ever had?What was the scale and scope of that work?SAFETYPlease list your workers' compensation experience modifier for the last three yearsEMR YEAREMR YEAREMR YEAREMR RATINGEMR RATINGEMR RATINGDoes your company have a written safety program? *YESNOIf yes, the the program and training records must be available for review upon request.Number of OSHA recordable injuries & illnesses from last year's OSHA 300 formHas your company received any OSHA/MIOSHA Violations/Penalties (types include Serious, Willful, Repeat, Other, Unclass) in the last 3 years? If Serious, Willful, or Repeat, please describe. *YESNOIf yes, the the program and training records must be available for review upon request.If yes, please describeAre toolbox talks held on jobsites by your lead foreman/supervisor on a weekly basis at minimum? *YESNOIf yes, the the program and training records must be available for review upon request.If yes, how are they documented?Do you provide Competent/Qualified Individual Trainings/Certifications for your employees? *YESNOIf yes, the names and/or training records must be available for review upon request.LEGALHas your company ever failed to complete any work awarded to it? *YESNOIf yes, please provide an explanation.Are there any pending or threatening judgements, claims, arbitration/mediation proceedings, or suits against your organization or its officer(s)? *YESNOIf yes, please provide an explanation.Has your organization filed any lawsuits or requested arbitration/mediation with regard to a construction contract in the last five years? *YESNOIf yes, the the program and training records must be available for review upon request.If yes, please provide an explanation.INSURANCEInsurance Company Name *LayoutInsurance Contact Name *Insurance Contact Phone *FINANCIALSWIP & BACKLOGTotal dollar value of contracts under contract & in process *Number of contracts in process *Average annual revenue over the last five years *BANKINGBank Name *LayoutBank Contact Name: *Bank Contact Phone *FINANCIAL STATEMENTSDOCUMEMT UPLOAD Click or drag files to this area to upload. You can upload up to 5 files. Please provide a copy of the company’s most recent audited/reviewed/compiled financial statements. If these are more than 6 months old, please also include the company’s most recent internal financial statements. GC/CM REFERENCESProvide three (3) GC/CM references below.REFERENCE #1 Contact Name *First NameLast NameLayoutREFERENCE #1 Company Name *REFERENCE #1 Phone *REFERENCE #2 Contact Name *First NameLast NameLayout (copy)REFERENCE #2 Company Name *REFERENCE #2 Phone *REFERENCE #3 Contact Name *First NameLast NameLayout (copy) (copy)REFERENCE #3 Company Name *REFERENCE #3 Phone *SUBMIT FORM
