Subcontractor Pre-Qualification Form

Fields marked with an * are required

Company Name *

Contact Person

Phone

Address

Address Line 1

City

State

Zip Code

Website / URL

Federal ID Number

Year Business Started

Number of Employees

Has Company or any of its Owners Declared Bankruptcy in last 5 year?

Is your company bondable?

Single Project Limit $ - Total $

Have you ever failed to complete a project? If yes, please explain below or write no.

Have you ever failed to complete a project on time? If yes, please explain below or write no.

Have you had a contract terminated due to performance? If yes, please explain or write no.

What is your current Worker's Compensation Experience Modification Rating (EMR)?

Number of jobs ran at one time

Annual Value $

Largest Job $

Average Job $

Current Contract Backlog:

Contractor's License (s) States and Numbers

* Please list Contractor's License (s) States and Numbers

Estimating Contact

Business Type

If your business type was not listed, please specify below

Please list your Company officers including their name, title, and number of years working with your company *

Is your company owned or controlled by a parent or any other organization? If yes, please explain below or write no.

Is your company a certified as a MBE, WBE, DBE, VBE, SBE, Native American, or N/A? Please list below or write N/A.

Are there any judgments, claims, arbitration proceedings, or suits pending/out-standing against your firm or its officers or principals? If yes, please explain below or write no.

Has your company filed any lawsuits or requested arbitration or mediation with regard to construction? contracts within the last three (3) years? If yes, please explain below or write no.

Banking References. Pleas list your bank name, branch, bank address, contact person, and how many years you have banked with them below.

Bonding References: Please list your bonding company, surety broker/agent, contact name with their phone number, bonding capacity project amount, and bonding capacity aggregate amount. Please also tell us us how long you have been working with each one

Please include a URL link to Google Drive or Dropbox folder that has a formal letter from your bonding company.

Insurance: Please list General Liability Carrier, insurance broker/age, and contact person with their telephone number. Please also tell us how long you have been in business with them. *

What is your limit to Liability insurance?

Please include a Google Drive or Dropbox document link with 5 References (Owner, Architects, and at least 2 General Contractors for work completed within the last 2 years). You must include the project description, company name, phone number, fax , and project amount $ for each

Financial Reference: Please include a Google Drive or Dropbox URL link to a copy of the following: Financial statement may be requested from J M Cope, INC. *

Has your company or any other organization with which your officers were involved during the past three (3) years, ever been in bankruptcy or a voluntary reorganization? If yes, please explain or write no.

Annual Volume: What was the annual volume of work completed in the last three years as well as next year’s forecast (Forecast Volume)

Does your firm have a written safety plan?

Has your firm had any OSHA citations, fines, or jobsite fatalities within the most recent three (3) years? If yes, please describe in detail what occurred and what steps were taken by the company to prevent from happening in the future.

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OSHA Incident Rate: Please list your firms OSHA incident rate for the most recent three (3) years

Please list any additional information you feel will help us determine your company’s qualifications and expertise.

Date

Please list your name and title

NOTE: J M COPE REQUIRES AN INSURANCE CERTIFICATE ON FILE INDICATING AUTO, GENERAL LIABILITY AND WORKER’S COMPENSATION INSURANCE AND EXPIRATION DATES; PLEASE EMAIL TO: office@jmcope.com NO SUBCONTRACTOR WILL BE PRE-QUALIFIELD WITHOUT INSURANCE OF FILE.

I hereby certify that the above information is accurate, correct and true.

Subcontractor Pre-Qualification Form

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