Subcontractor Pre Qualification Application (Page 4 of 6) in pdf

Subcontractor Pre Qualification Application Page 4

3. Bidding Interest

Complete Attachment “A” – Bidding Interest to indicate the classifications your

firm is interested in bidding.

4. References

A. Please list three (3) trade credit references (who you purchase from the

most):

1. Company Name: ____________________________________________

Contact Person:

____________________________________________

Phone Number:

____________________________________________

Credit High Dollar Amount: ____________________________________

2. Company Name: ____________________________________________

Contact Person:

____________________________________________

Phone Number:

____________________________________________

Credit High Dollar Amount: ____________________________________

3. Company Name: ____________________________________________

Contact Person:

____________________________________________

Phone Number:

____________________________________________

Credit High Dollar Amount: ____________________________________

5. Safety & Insurance

A. Name of insurance company: _____________________________________

Name of insurance agent: ________________________________________

Phone number: _________________________________________________

B. Do you have a Workers Compensation policy or are you exempt?

_____ Have policy

_____ We are exempt

C. Please state your Workers Compensation experience modification rate for the

past three (3) years:

This Year: ________

Last Year: ________

Previous Year: ________

Page 4 of 6

Subcontractor Pre Qualification Application Page 4