Subcontractor Pre-Qualification Form (PQF)

Company Name:

Address: City: State: ZipCode: Country: Phone: Fax: Website: Mailing Address: Email:

Name: Email: Telephone: Fax:

Name: Telephone:

Title: Fax:

Email: Date Completed:

Organization Established: Incorporation Country: Date of Registration:

Parent Organization Name: Address: City:

Additional Address: Subsidiaries:

State:

Organization Type: Incorporation State: Federal Tax ID:

ZipCode: Country:

Are you a member of Associated Builders & Contractors (ABC) Yes No

President Name:

Vice-President Name:

Treasurer Name:

Above Management Team has been in place since (Date):

Years with Company:

Years with Company:

Years with Company:

COMPANY OFFICERS (Contacts Tab)

PARENT COMPANY INFORMATION (Additional Info Tab)

PQF COMPLETED BY (Contacts Tab)

CONTACT FOR REQUESTING BIDS (Contacts Tab)

GENERAL INFORMATION (Info Tab)

Does your firm qualify as a:

SMALL BUSINESS CONCERN? (As defined pursuant to Section 3 of the Small Business Act, criteria prescribed by the Small Business Administration, CFR, Title 13, Part 121, as amended, and/or other relevant regulations?)

Yes No If yes, attach a copy of your certificate

SMALL DISADVANTAGED BUSINESS CONCERN? (Qualified as a small business & owned and controlled by socially or economically disadvantaged individual; commonly referred to as a Minority Business Enterprise or MBE?)

Yes No If yes, attach a copy of your certificate

WOMEN OWNED or CONTROLLED SMALL BUSINESS? (Must be qualified as a small business under criteria & size standards in CFR, Title 13, Part 121, as amended, commonly referred to as a Woman Business Enterprise or WBE?)

Yes No If yes, attach a copy of your certificate

Average Number of Executive Management: Average Number of Office Management/Staff: Average Number of Shop/Equipment Management/Staff:

Average Number of Job Site Management/Staff: Average Number of Trades People:

Do you employ Union Personnel? If yes, please list Local Number, Trade Name & Expiration:

Local #: Trade Name: Expiration:

Local #: Trade Name: Expiration:

Local #: Trade Name: Expiration:

Please provide the State Name, License # and Expiration Date of any state your firm is licensed in:

State:

State: License #:

License #:

Expiration:

Expiration:

State: License #: Expiration:

State:

State:

License #:

License #:

Expiration:

Expiration:

State: License #: Expiration:

BANK INFORMATION (Financial Tab)

Bank Name: Branch: Years with Bank: Line of Credit Total: Bank Address:

Contact: Phone: Email: Line of Credit Expiration:

Fax:

City: State: ZipCode: Country:

STATE LICENSURE (States Tab)

(Unions Tab)

COMPANY SIZE (Headcount Tab)

BUSINESS ORGANIZATION (Certificates Tab)

Yes No

UNION PERSONNEL

Dunn & Bradstreet

#: Revenue Year:

Net Income:

Dunn & Bradstreet Rating:

Revenue Amount:

Net Equity:

Name: Title:

Telephone: Fax: Email:

Insurance Agency:

Agent Phone:

Contact:

Years with Agent:

Agency Address:

City: State:

Agent Name:

Agent Fax:

Email:

ZipCode: Country:

Carrier:

Policy Form:

Policy Period From:

Policy Number:

To:

Each Accident: Disease Limit: Disease/Employee:

Carrier:

Policy Form:

Policy Period From:

Deductible:

Policy Number:

To:

Project Limit:

Carrier: Policy Form:

Policy Period From:

Policy Number:

To:

Number of Claims Made: General Aggregate:

Any Exclusions to Standard CGL? Products & Completed Operations:

COMMERCIAL GENERAL LIABILITY (Liability Tab)

PROFESSIONAL LIABILITY INSURANCE (Insurance Tab)

WORKERS COMPENSATION & EMPLOYERS LIABILITY (Insurance Tab)

INSURANCE AGENCY INFORMATION (Insurance Tab)

COMPANY CONTACT FOR INSURANCE INFORMATION (Contacts Tab)

FINANCIAL & DUN & BRADSTREET INFORMATION (Financial Tab)

Yes No

Carrier:

Policy Form:

Policy Period From:

Type:

Do you Have Business Auto Insurance for all owned, hired and non-owned vehicles with minimum limits of $1,000,000 combined single limits? Yes No

Carrier:

Policy Form:

Policy Period From:

Policy Number:

To:

SURETY COMPANY INFORMATION (Bonding Tab)

Surety Name:

Surety Broker Name:

Contact:

Phone:

Capacity per Job:

State:

Email:

Fax:

Bonding Capacity Limit:

Country:

LARGEST PROJECT INFORMATION (Projects Tab)

LARGEST PROJECT EVER

Year: Customer:

Dollar Value of Work: Project Name: Your Scope of Work:

LARGEST PROJECT THIS YEAR Dollar Value of Work: Project Name: Your Scope of Work:

LARGEST PROJECT LAST YEAR

Year: Customer:

Year: Customer:

Dollar Value of Work: Project Name: Your Scope of Work:

What is your firm's desired project size? Maximum: Minimum:

AUTOMOBILE LIABILITY (Liability Tab)

EXCESS LIABILITY (Liability Tab)

Policy Number:

Policy To:

Number of Claims Made:

Zip Code: SuretyAddress:

Years with Surety:

Has your firm at any time failed to complete a contract, had a contract terminated for cause or other similar adverse reason, failed to perform to standards, etc.? Yes No If yes, please attach details

Has your company or any of its principals ever petitioned for bankruptcy, failed in business, defaulted or been terminated on a contract awarded? Yes No If yes, please attach details

Have any of the owners, officers or major stockholders ever been indicted or convicted of any felony or other criminal conduct? Yes No If yes, please attach details

Has your company or any of the owners, officers or major stockholders ever been suspended, disbarred or otherwise precluded from perusing public work or ever been found to be non-responsive to a public agency? Yes No If yes, please attach details

Has your company ever had a claim made against it for improper, delayed, defective or non-compliant work or failure to meet warranty obligations? Yes No If yes, please attach details

Is your company or any of the owners, officers or major stockholders involved in any arbitration or litigation? Yes No If yes, please attach details

Are there any judgements, claims, liens or suits pending/outstanding against your firm or I s your firm currently in litigation, are there injunctions either for or against your firm, etc.? Yes No If yes, please attach details

Has your company or any of the owners, officers or major stockholders ever been investigated for, or charged with, alleged labor law violations including alleged violations of Immigration Control and Reform Act; state or local laws regarding employment of immigrants; prevailing wage and hour laws or other federal, local or state labor laws? Yes No If yes, please attach details

Customer: Type of Work: Customer Contact:

Customer: Type of Work: Customer Contact:

Customer: Type of Work: Customer Contact:

Location: Size $M: Telephone:

Location: Size $M: Telephone:

Location: Size $M: Telephone:

Customer: Type of Work: Customer Contact:

Customer: Type of Work: Customer Contact:

Customer: Type of Work: Customer Contact:

Location: Size $M: Telephone:

Location: Size $M: Telephone:

Location: Size $M: Telephone:

MAJOR JOBS COMPLETED IN THE PAST THREE YEARS (Project Type Tab)

MAJOR JOBS IN PROGRESS (Project Type Tab)

LEGAL QUESTIONS (Legal Tab)

Check the categories in which you are interested in bidding and in which you are qualified to perform work. Attach additional information clarifying your capabilities and specialties.

(C) Denotes work done by your company employees (S) Denotes work done by subcontractors

Air Conditioning – HVAC Pickling & Passivation Air Conditioning – Process Cooling

Pipe / Angle Rolling Building – New Pipe Fabrication Building – Remodeling

Railroad - Construction Cathodic Protection Railroad – Emergency Derailment Svcs

Railroad - Maintenance Civil – Asphalt Supplier Railroad - Repairs Civil – Asphalt Installation Railroad - Switching Civil – Auger Cast Civil – Concrete Finishing Refractory Civil – Drilling/Boring Civil – Excavating/Grading Rigging / Equipment Erection Civil – Paving Civil – Pile Driving Sand Supplier Civil – Pre-Cast Piles Civil – Rebar Fabrication Scaffold Rental & Erection Civil – Tank Foundations

Structural Erection Cleaning – Industrial Structural Fabricator

Cold Cutting Tanks – Aluminum IFR Tanks – API-653 Inspection

Consulting – Chemical Tanks – Bolt-On Foam Dams Consulting – Instrumentation Tanks – Drain Hoses Consulting – Electrical Tanks - Erection Consulting – Engineering Tanks – Floor Scan Consulting – Mechanical Tanks – Geodesic Dome Consulting – Metallurgical Tanks - Jacking

Tanks – Misc. Tank Accessories Crane Tanks – Plate Processing (Cutting)

Tanks – Plate Processing (Rolling) Demolition – Miscellaneous Tanks - Seals Demolition – Tanks Tanks - Skimmers

Tanks – Steel Dome Roof Fabrication Tanks – Strapping / Calibration

Electrical – General Tanks – Structural Fabricator (Roof) Electrical – Grounding Systems Tanks – Structural Fabricator (Tank Access) Electrical – High-Voltage

Water Filtration

Field Painting Fireproofing

FRP – Misc. – Grating, etc FRP – Piping FRP – Tanks

Galvanizing

Gaskets

General – Boiler Code General – Cooling Tower General – Field Machining General – Glass lining

General – Heat Treating General – High Alloy Welding General – Hot Tap/Line Stops General – Lead Lining General – Leak Sealing General – Mobil Equipment Repair General – Non-Metallic Materials General – Rotating Equipment General – Storage/Material Handling General – Tank/Vessel Code General – Valve General – Exchanger Re-tubing

HDPE Installation HDPE Supplier

Heat Tracing

Helium Leak Testing

Hydro Test Supplies

Inspect & Testing – Acoustic Emissions Inspect & Testing – Civil/Soils Inspect & Testing – Column Scanning Inspect & Testing – Eddy Current Inspect & Testing – Electrical Ground Inspect & Testing – Fiberglass Inspect & Testing – General NDE Inspect & Testing – High Voltage Electrical Inspect & Testing – Infrared Scanning Inspect & Testing - Radiography Inspect & Testing – Rope Access Inspect & Testing – Ultra Sonic Testing

Instrumentation – Analyzers Instrumentation – DCS Control Systems Instrumentation – Field Bus Instrumentation – General

Insulation – Asbestos Abatement Insulation – General

Lead Abatement

Liners – (HDPE)

Marine – Dock Installation Marine – Dock Maintenance Marine – Dredging Marine – Underwater Welding

Painting - Field Painting - Shop

PHWT - Field PWHT – Shop

WORK CATEGORIES (Scope/Phase Tab)

C S C S C S

Describe any other additional services:

WORKERS COMPENSATION EXPERIENCE MODIFICATION RATE (EMR) DATA

EMR is :Dual Rate Not Required

EMR for last three years: EMR: EMR:

YR: YR: YR: EMR:

EMR Anniversary Date: State of Origin:

Standard Industrial Code (SIC):

North American Industry Classification System (NAICS):

INJURY & ILLNESS DATA HOURS per YEAR YR: YR: YR:

Average # of Employees Field Hours Office Hours TOTAL HOURS

PROVIDE DATA (excluding subcontractor) USING YOUR OSHA 300 FORMS FROM THE PAST 3 YEARS 1- Data should be the best available data applicable to the work in this region or area.2- If your company is not required to maintain OSHA 300 forms, please provide information from your Worker’s

Compensation insurance carrier itemizing all claims for the last 3 years.3- If data is being provided after July 31st, please include current YTD cumulative.

YR: YR: YR: No. Rate No. Rate No. Rate

Fatalities: Rate = Number of Fatalities x 200,000 / Total Employee Hours

(OSHA Log Column G)

Lost Workday Case Injuries & Illnesses: - Involving daysaway from work, or days of restricted work activity or both Rate = Total LW and restricted cases x 200,000 / Total Employee

Hours (OSHA 300 Log, Total of Columns H & I)

Lost Workday Case Injuries and Illnesses: - involving daysaway from work Rate = LW cases ** x 200,000 / Total Employee Hours

(OSHA Log, Column H)

Injuries and Illnesses Involving Medical Treatment Only: Rate = Total Injuries and Illnesses involving medical treatment

Only x 200,000 / Total Employee Hours (OSHA 300 Log, Column M, 1-6)

Total OSHA Recordable Injury and Illness Rate:

Rate = Total injuries and illnesses x 200,000 / Total Employee Hours

Average TRIR:

Have you received any regulatory (EPA, OSHA, etc.) citations in the last three years? Yes NoIf yes, please attach copies.

SAFETY & HEALTH PERFORMANCE (Performance Tab)

Interstate Rate Intrastate Rate Monopolistic State Rate

Name of the highest ranking safety/health professional in the company: Title: Email: Telephone: Fax: Certifications:

Yes No Do you have or provide: Safety/Health Incentive Program?

Company paid Safety/Health training?

Yes Do you have or provide: Full time Safety/Health Director? Full time Safety/Health Supervisor?Full time Safety/Health Coordinator?

Do you have a written Safety, Health & Environmental Program/Manual?

Does the program/manual address the following key elements:

Yes Management commitment and expectations?

Yes Employee Participation?

Yes Accountabilities and responsibilities for managers, supervisors and employees?

Yes Resources for meeting safety, health and environmental requirements?

Yes Behavioral based safety?

Yes Periodic safety and health performance appraisals for all employees?

Yes Safety, Health & Environmental Recognition Program?

Yes Hazard recognition and control?

Yes Specific safety, health and environmental training program for supervisors?

Does the program/manual satisfy your responsibility under the law for:

Yes Yes

Ensuring your employees follow the safety rules of the facility? Advising owner of any unique hazards presented by the contractor’s work, and of any hazards found by the contractor?

Does the program/manual include work practices and procedures for:

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Equipment Lockout and Tagout (LOTO) Confined Space Entry Fall Protection Injury & Illness Recording Personal Protective Equipment Portable Electrical/Power Tools Vehicle Safety/Maintenance Inspections Compressed Gas Cylinders Electrical Equipment Grounding Assurance Housekeeping Accident/Incident Reporting Unsafe Condition Reporting General NDT & Radiography Back Injury Prevention

Yes

Heat Stress Prevention Ergonomics Hazwoper Training Short Service Workers Program? Asbestos Benzene Radiation Excavations Fire Watch Hole Watch Scaffold Building Scaffold Use Blood borne Pathogens Lead

SAFETY, HEALTH & ENVIRONMENTAL PROGRAMS & PROCEDURES (Procedures Tab)

SAFETY, HEALTH & ENVIRONMENTAL MANAGEMENT (Safety Tab)

No

No

No

No No No No No

No No

Yes No

No No

No

No

No No No No No No

No No No No

No

No

No

No No No No No No

No No No No

No Yes No Yes No

Yes Yes Yes

Yes Yes

Yes

Air Monitoring (Welding, lead, asbestos, etc.) Emergency Preparedness, including evacuation plan Waste Disposal/Waste Minimization/Spill Prevention Powered Industrial Vehicles (Cranes, Forklifts, JLG’s. etc.) Specialized Equipment (e.g., Hydro blast, Exchanger Extractors, etc.)

Where applicable, have employees been:

Yes

Yes

Do you have written programs for the following:

Trained

SUBSTANCE ABUSE PROGRAM

Annual % Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Do you have a substance abuse program? If yes, does it include the following: NASAPPre-employment Testing Random Testing Testing for Cause DOT Testing Post Incident Testing Do you belong to a drug consortium? Hair Testing Urinalysis Do all employee’s get tested at least every 12 months?

BACKGROUND SCREENING PROGRAM

Yes Yes Yes Yes

Do you have a background screening program? If yes, please attach policy NABSC - North American Background Screening Consortium First AdvantageTWIC - Transportation Worker Identification Credential Other

ENGLISH LANGUAGE

Yes Do your employees read, write, and understand English such that they can perform their job tasks safely without an interpreter? If no, provide a description of your plan to assure they can safely perform their jobs.

Hearing Conservation Respiratory Protection Hazard Communication Spill Prevention & Waste Minimization Program to support the contractor requirements of the OSHA Process Safety Management of Highly Hazardous Chemicals; Explosives and Blasting Agents Standard (29 CFR 1910)

No

No

No

No

No

No

No

No

No

Yes

Yes No

Yes No Yes No Yes No Fit Tested Medically Approved

Have Employees been trained?

Have Employees been trained?

Yes

Yes

No

No

No

No

No No No No No No No No

No

No

No

No No

No

Yes No

Crane Operators Other

Describe how you will provide first aid and other medical services for your employees while on-site. Please specify who will provide this service.

Yes Yes Yes

I have personnel trained in performing First Aid I have personnel trained in CPR - Cardiopulmonary Resuscitation I have personnel trained in AED - Automated External Defibrillator

SAFETY MEETINGS

Do you hold site safety and health meetings for:

Yes Field Supervisors Frequency:

Yes Employees Frequency:

Yes New Hires/Transfers Frequency:

Yes Subcontractors Frequency:

Yes Are the safety and health meetings documented?

PERSONAL PROTECTION EQUIPMENT (PPE)

Yes Is applicable PPE provided for employees?

Yes Do you have a program to assure that PPE is inspected and maintained?

EQUIPMENT & MATERIALS

Yes Do you have a system for establishing applicable health, safety and environmental specifications for acquisition of materials and equipment?

Yes Do you conduct inspections on operating equipment(e.g., cranes, forklifts, JLGs) in compliance with regulatory requirements?

Yes Do you maintain operating equipment in compliance with regulatory requirements? Yes Do you maintain the applicable inspection and maintenance certification records for operating equipment?

SUBCONTRACTORS

Yes Do you use subcontractors? Yes Do you use safety and health performance criteria in selection of subcontractors?

Yes Do you evaluate the ability of subcontractors to comply with applicable health and safety requirements as part of the selection process?

MEDICAL

Yes Yes Yes Yes Yes

Do you conduct medical examinations for Pre-employment Pre-placement Job Capability Hearing Function (Audiograms) Pulmonary Respiratory

Yes

Yes

No

No

No No

No No

No

No No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

INSPECTIONS & AUDITS

Yes Yes Yes

Do you conduct safety and health inspections? Do you conduct safety and health program audits? Are corrections of deficiencies documented? Do you include your subcontractors in Inspections & Audits

Yes Do you know the regulatory safety and health training requirements for your employees? Yes Have your employees received the required safety and health training and retraining and is it documented? Yes Do you have a specific safety and health training program for supervisors? Yes Are all employees trained in the work practices needed

Yes Is each employee instructed in the known potential of fire, explosion, or toxic release hazards related to his/her job, the process and the applicable provisions of the emergency action plan?

Yes Do your employees have a current “Basic Plus Refresher” card offered through the Association of Reciprocal Safety Councils, Inc. (i.e. GBRIMA, GNOIEC, etc.)

NOTES: 1 - Data should be the best available applicable to the workforce in this region or area

2 - Skills Assessment for the Houston area (including Baytown, Texas City, etc.) means either the National Skills Assessment or the ISAC Skills Assessment. For other areas, if applicable, it would be the skills assessment process approved in the area.

3 - Skill assessments is not required for helper/trainer/laborers or for craft employees who have either A - completed Wheels of Learning (WOL) or Department of Labor Bureau of Apprenticeship Training (DOL BAT) or B - are participating in WOL or DOL BAT.

Does your company participate in a nationally recognized training, skills assessment testing or performance verification Program such as NCCER, NCCCO, DOL BAT or other?

WORKFORCE

# of Employees % of Workforce

Journeymen Craftsman covered by NCCR or DOL BAT Programs Sub-Journeymen Trainees (NCCER or DOL BAT COVERED Helper/Trainees Non-covered Journeymen Craftsmen Non-covered Journeymen Craftsmen/Trainees/Helpers Supervision (Foreman/General Foreman) Professional (Safety/Scheduling/Engineering) Administration/Management TOTAL WORKFORCE

CRAFT TRAINING & ASSESSMENT (Training Tab)

SAFETY & HEALTH TRAINING (Training Tab)

No No

Do you have a corrective action process for addressing individual safety and health performance deficiencies? Yes No

If yes, please use the last twelve months average data to complete your company’s workforce below.

Data time frame From: To:

If N/A, please explain:

Do you have written Workforce Development Policies & Procedures? Yes

No

No No No

No

No

No

Yes No

TRAINING

Do you have and maintain craft training records for employees? If yes, percentage:

Percent of Craft Employees who have completed Wheels of Learning or DOL Bureau of Apprenticeship Training

Percent of Craft Employees presently enrolled in Wheels of Learning or DOL Bureau of Apprenticeship Training

If employees have not completed or are not enrolled in Wheels of Learning or DOL Bureau of Apprenticeship Training, have they been trained in appropriate job skills

ASSESSMENTSASSESSMENTS

# of Employees % of Workforce Craftsmen who have been assessed through the craft skills assessment process (See Note 3)

Craftsmen who have been assessed with “no deficiencies” identified.

Craftsmen who have been assessed with training needs (WOL modules) identified.

Craftsmen who have not been assessed through the skills assessment.

Craftsmen assessed with training needs identified who have completed upgrade training

Craftsmen who have been certified in more than one craft?

Craftsmen with skill deficiencies identified through assessment Testing and receiving upgrade training?

Where appropriate are training needs being addressed through skill upgrade training?

For those employees for whom there is not a skills assessment available, do you have a process to assess the skills of your workers to assure they are qualified (Please attach explanation)

Are employees job skills certified where required by regulatory or industry consensus standards. (Please attach a list of the crafts which have been certified)

Do you provide incentives for craftsmen to become certified?

Do craftsmen have access to upgrade training to improve skills?

Is Company an accredited NCCER Assessment Center?

HELPER/TRAINEES " of Employees % of Workforce

Helpers who are enrolled in Wheels of Learning or DOL Bureau of Apprenticeship Training

Yes

Yes

No

No

Helpers who are not enrolled in Wheels of Learning or DOL Bureau of Apprenticeship Training

PERFORMANCE VERIFICATION " of Employees % of Workforce

Journeymen craftsmen that have achieved verified performance

Journeymen craftsmen that have achieved both written certification and verified performance

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

Yes No

PLEASE PROVIDE COPIES OF THE FOLLOWING WITH YOUR COMPLETED PQF:

Fill in below the Name, Title & Contact information of the Company Officer responsible for assuring the accuracy of this document:

Contact: Title:

Telephone: Date:

PQF EVALUATION – PALA INTERSTATE LLC USE ONLY (Additional Info Tab)

INFORMATIONAL SUBMITTAL (Submittal Tab)

Qualified – Acceptable for Approved Contractor List Notes:

Conditional – Conditionally acceptable for Approved Contractor List Conditions:

PreferredNotes:

Do Not Use – Do Not Use on Future Projects Notes:

>OSHA 300 & 300A Logs (Past 3 Years)>EMR Documentation from your Insurance Carrier>State Contractors License