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 RATING - 2020EMR RATING - 2021EMR RATING - 2022Does 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
