Subcontractor Qualification Statement Please provide electronic copies of the following with this form: EMR Documentation from your Insurance Provider OSHA 300 Logs for the past 3 years
A.
General Year Est.:
Legal Name of Business: Office Mailing Address: City: Phone No:
State:
Zip Code:
EIN #
Company Website: Labor Affiliation: Minority Designations: Do you have In House Engineering Capacity (circle one):
Yes
No
Do you have In House Fabrication Capacity (circle one):
Yes
No
List all States in which your orgainization is legally qualified to do business:
List all trades that your company is interested in bidding:
Please list any contacts who should receive Invitations to Bid: Name:
Position:
PH:
Email:
Name:
Position:
PH:
Email:
Name:
Position:
PH:
Email:
Total number of employees:
1
B.
Safety
Has your company received an OSHA (or state OSHA) or MSHA citation within the last five (5) years: If Yes, please explain:
Does your company have a written occupationals safety & health program:
Yes
No
Yes
No
Does your company conduct field safety audits to determine compliance w/ applicable regulations & procedures: Yes
No
Who conducts these audits: How often are safety audits conducted: Please list your company's Experience Modification Rate (EMR) for the three (3) most recent years: Policy Year
Interstate
Intrastate (If Applicable)
Please list your company's TRIR for the three most recent years: Policy Year
Interstate
Intrastate (If Applicable)
Number of Fatalities in the past 3 years: Number of OSHA Citations in the past 3 years: Explanation:
(Explain below or attach a separate sheet as necessary)
2
C.
Experience
Please list three (3) of the most significant projects completed in the last five (5) years: Location
Project Name
Work & Contract Amount
Award Date
What's your company's annual volume: Please provide up to three (3) owner references: Owner Reference: (Co. Name)
(Contact)
(Phone)
(Co. Name)
(Contact)
(Phone)
(Co. Name)
(Contact)
(Phone)
Owner Reference: Owner Reference:
Please provide electronic copies of the following with this form: EMR Documentation from your Insurance Provider OSHA 300 Logs for the past 3 years
Please send completed forms to amy.hewis@theaustin.com
Thank you
3