Subcontractor / Supplier Prequalification Form (Page 3 of 5) in pdf

Subcontractor / Supplier Prequalification Form Page 3

Contact for insurance information:

Title:

Phone:

Fax:

Email:

Insurance Carriers:

Name

Type of Coverage

Telephone

□

Does your company have a Performance and Payment Bond program?

Yes

Bonding capacity:

Bonding Company contact:

Limits:

Title:

Phone:

Fax:

Email:

Percentage of self-performed work:

Percentage of subcontracted work:

□

Do your subcontractors carry Workers’ Compensation Insurance?

Yes

If no, please explain:

TRAINING

List the various training programs your company provides to its employees (i.e., LEED, craft training, etc.):

Are you willing to participate in MaineHousing’s On the Job Training Program if

□

needed?

Yes

SAFETY & HEALTH

Workers Compensation Experience Modification Rate (EMR) for the last three years:

20______ - ________

Have you received any regulatory (EPA, OSHA, etc.) citations in the last three years?

□

Yes

If yes, please attach copies.

AlliedCook Construction 11.09

prequalification form.doc

Subcontractor / Supplier Prequalification Form Page 3