subcontractor prequalification form final 08-04-2015 · yes no (a copy will be required if selected...

5805 Wagon Wheel Lane Lakeside, AZ 85929 Phone (928) 537-2920 Fax (928) 537-2922

S:\Forms\Subcontractor Qualification\subcontractor prequalification form final 08-04-2015.doc.docx

Prequalification Form will NOT be accepted unless completed in its entirety.

Please check the state that you are submitting your qualifications for: AZ NM UT

Business Information Company Name:

Primary Address 1:

Primary Address 2:

City: State: Zip Code: Country:

First Name: ______________ Last Name: ___________________________________

Phone: Fax:

E-mail:

Other Branch Offices:

Design/Build Experience: Yes No

If Yes, engineering staff is: Internal External Years in Business Under Present Name: Years Status: Union Non-Union

Employer Identification No.: State Contractors License Number (where applicable) Average Contract Size over the last five (5) years $ Average annual revenue over the last five (5) years $ Company Type: Corporation Partnership LLC Individual

DBA Joint Venture Sole Proprietor

Work Performed Please see the attached list of Construction Codes and mark all that your company typically performs

Check the categories your company has experience in:

Healthcare Education Higher Education

Apartments Condos Single Family Homes

Industrial Retail Other Commercial ________________

KMcWhorter

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KMcWhorter

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5805 Wagon Wheel Lane Lakeside, AZ 85929 Phone (928) 537-2920 Fax (928) 537-2922 S:\Forms\Subcontractor Qualification\subcontractor prequalification form final 08-04-2015.doc.docx

Business Classification Does your business meet a special classification: Yes No If yes, please complete the remainder of this section.

Minority Owned Woman Owned Small Business

Disadvantaged Business HubZone Veteran Owned

Other 1 Other 2 Other 3

Minority Certification Status: N/A Self Public Private

City: NMSDC Affiliates: State: (National Monitory Supplier Dev. Council) Country:

Insurance Is your company Insurable? Yes No

Can your company comply with the attached Insurance Requirements? Yes No

If not please list your current insurance limits below:

General Liability Coverage Limits: ______ Auto Coverage Limits:

Umbrella Policy Limits:

Workers Compensation Limits:

Bonding Is your company bondable? Yes No (If N/A or not bondable, please provide explanation.) Bonding capacity in aggregate: $ Bonding capacity per projects $ (Current $$ value required, DO NOT state unlimited) Bonding Rate per $1,000: Bonding Company (Surety, not Agent): (List complete Surety Name as it appears on the Dept. of Treasury’s Listing of Approved Sureties (Dept. Circular 570)

Past Performance Has your organization ever failed to complete any awarded work in the last seven (7) years? Yes No (If Yes, attach explanation) Are there any judgments, claims, arbitration proceedings and/or suits pending against your organization or its officers in the last seven (7) years? Yes No (If Yes, attach explanation)

Has your organization filed any lawsuits or requested arbitration with regard to construction contracts within the last seven (7) years? Yes No (If Yes, attach explanation)


Safety Has your organization incurred any OSHA violations over the past three years? Yes No If yes, how many? What is your organizations’ Workers Comp EMR history for the past 3 years & the current year? Currents Year ; 1 Year Ago ; 2 Years Ago ; 3 Years Ago

What is the business’ OSHA recordable incident rate for the past 3 years & the current year? (Number of recordables X 200,000 / man-hours worked) 1 Year Ago ; 2 Years Ago ; 3 Years Ago _______

Has your organization incurred any fatalities over the past three years? Yes No If yes, how many? Does your organization have a written safety policy? Yes No (A copy will be required if selected for project)

Does your company comply with the Drug Free Work Act? Yes No

References List Contact information for three (3) projects and owners, general contractors, or construction managers for whom the company has worked in the past 5 years below: Project General Contractor Phone Email Contract & Contact Name Amount _______________________ _______ _______________________ _______ _______________________ _______

List Contract information for three (3) suppliers from whom the company has purchased materials or subcontractors which the company has hired in the past 5 years below: Company Contact Phone Email or Fax ______ __________ ______

List Fiduciary institutions with whom your company does business with: Bank Type of Account Account # Contact Phone ______________ ______________ ______________

Financial Status Dunn & Bradstreet #: Dunn & Bradstreet Rating: Working Capital: I have enough working capital to cover payroll for 30 days 60days

The undersigned certifies that the information provided herein is true and sufficiently complete so as not to be misleading.

Completed By: (Print or Type) (Signature) Title: Date Completed:


To be completed by Whiteriver Construction, LLC. Estimator Comments:

Approved Called References Not Approved

If not approved why and how can we get the approval: _______________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Comments:_________________________________________________________________________________________________ _________________________________________________________________________________________ _____________________________________________________________________________________ Estimator Signature Date

Project Manager Comments:


If not approved why and how can we get the approval: _______________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Comments__________________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Project Manager Signature Date Arizona Division Manager Comments:


If not approved why and how can we get the approval: _______________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Comments:_________________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Arizona Division Manager Signature Date

Check codes you will bid

Code Code Description01137 Engineering Services01330 Surveying01400 Quality Control / Requirements01410 SWPPP Design01500 Temporary Construction Facilities01515 Final Cleaning02000 Site Construction02050 Demolition02070 Asbestos Abatement02075 Saw Cutting 02120 SWPPP Implementation02300 Earthwork02350 Piles & Caissons02360 Steel Helical Piles02361 Termite Control02500 Paving02510 slurry Seal02513 Asphalt Concrete Paving 02580 Pavement Marking02600 Site Utilities02685 Liquid Petroleum02688 Natural Gas Systems02720 Storm Drainage02751 Cement Concrete Pavement02830 Fencing02840 Parking Barriers02842 Parking / Traffic Signage02900 Landscaping03000 Concrete 03110 Curbs & Gutters03200 Concrete Reinforcement03400 Auger Cast in Place Piles03500 Cementations Decks & Underlayment's 03900 Concrete Restoration & Cleaning04000 Masonry 04400 Stone04700 Simulated Masonry04900 Masonry Restoration & Cleaning05000 Metals 05100 Structural Metal Framing05101 Structural Corrections05200 Metal Joists05300 Metal Deck05400 Cold Formed Metal Framing05500 Metal Fabrications05510 Metal Stairs 05520 Handrails & Railing05700 Ornamental Metal06100 Rough Carpentry

Construction Codes

Code Code Description

06110 Sub Floor Framing06112 Exterior Gypsum Sheathing06150 Siding & Exterior Trim 06180 Glued Laminated Beam06190 Truss (Prefab)06200 Finish Carpentry06400 Custom Casework07000 Thermal & Moisture Protection 07100 Waterproofing 07150 Damp Proofing 07180 Water Repellants07190 Vapor Barrier07200 Insulation 07210 Loss Fill Insulation 07240 EIF System / Stucco07250 Fireproofing07310 Shingle Roofing 07400 Metal Roofing07500 Membrane Roofing07600 Flashing & Sheet Metal07625 Gutters & Downspouts07700 Roof Specialties & Accessories07800 Fire & Smoke Protection07842 Fire Resistive Joint Systems07900 Joint Sealers08150 Metal Doors & Frames08200 Wood & Plastic Doors08300 Specialty Doors08311 Access Door08360 Overhead doors08400 Entrances & Storefronts08500 Windows08520 Aluminum Windows08565 Vinyl Windows 08600 Skylights 08610 Wood Windows08700 Hardware 08800 Glazing08900 Glazed Curtain Wall09005 Countertops09100 Metal Support Assemblies09110 Metal Studs09200 Stucco09260 Gypsum Drywall09300 Flooring09310 Ceramic tile 09400 Terrazzo09500 Acoustical Treatment09510 Acoustical Ceilings09530 Sound Attention Blankets09600 Resilient Athletic Flooring


09640 Stone Flooring 09650 Resilient Tile Flooring 09660 Resilient Flooring09680 Carpet 09700 Wall Finishes09742 Epoxy Polyurethane Floor09900 Paints & Coatings09950 Wall Coverings Coating10100 Visual Display Boards10150 Compartments & Cubicles10155 Toilet Compartments10200 Lovers & Vents10263 Corner Guards10300 Fireplaces & Stoves10350 Flagpoles10400 Identification Devices10500 Lockers 10521 Fire Extinguishers & Cabinets10550 Postal Specialties10600 Partitions10670 Shelving 10800 Bath Accessories10900 Wardrobe & Closet Specialties11050 Library Theft Detection 11100 Mercantile Equipment 11400 Food Service Equipment 11450 Appliances 11470 Photo Laboratory Equipment 11480 Athletic Equipment11600 Laboratory Equipment 11700 Medical Equipment 11900 Detention Doors & Gates12000 Furnishings12010 Furniture /Fixtures12300 Manufactured Casework12400 Furnishings & Accessories12450 Window Coverings12500 Projection Screens12600 Multiple Seating12700 Floor Mats13121 Pre Engineered Buildings 13200 Storage Tanks13700 Security Access & Surveillance 13800 Buildings Automation & Control 13900 Fire Suppression 14000 Conveying Systems 14100 Utility Connections to Modular14125 ADA Access Lift 14200 Elevators14300 Escalators & Moving Walks14400 Lifts


15000 Mechanical 15100 Plumbing15300 Fire Protection Piping15700 HVAC 16000 Electrical16400 Low Voltage Distribution 16500 Lighting 16700 Communications16720 Fire Alarm Systems16725 Security Systems16800 Sound & Video

Subcontractor Insurance Requirements

Whiteriver Construction, LLC.’s general liability carrier requires all subcontractors wishing to do business with Whiteriver to meet the following basic insurance requirements:

1. General Liability Policy which is written on an occurrence basis and provides the following endorsements:

a. Waiver of Subrogation in favor of Whiteriver Construction b. Additional Insured Status for Whiteriver Construction, ongoing and completed

operations. c. Primary & Non-Contributory wording d. Policy must provide the following minimum limits of insurance:

$1,000,000 – Any One Occurrence

$2,000,000 – Products/Completed Operations Aggregate

$2,000,000 – Project Aggregate 2. Business Auto Policy which provides the following minimum limit of insurance:

$1,000,000 Any One Occurrence

Waiver of Subrogation in favor of Whiteriver Construction

Additional Insured Status for Whiteriver Construction 3. Workers’ Compensation Policy which provides the following minimum limit of

insurance:

$1,000,000 E.L., Each Accident

$1,000,000 E.L., Disease EA Employee

$1,000,000 E.L., Disease – Policy Limit

Waiver of Subrogation in favor of Whiteriver Construction

Statutory coverage for states where work is being performed 4. Umbrella Policy endorsed to increase limits for the General Liability, Business Auto and

Workers’ Compensation Policy and providing the following minimum limit of insurance:

$2,000,000 Any One Occurrence

$2,000,000 Aggregate 5. Professional Liability Policy (If Applicable) must provide the following minimum

limits of insurance:

$1,000,000 – Any One Occurrence

A Certificate of Insurance verifying coverages and copies of all endorsements must be provided to Whiteriver Construction prior to the start of work. Certificate should include a 30-day notice of cancellation, except for 10-day notice for non-payment. A Sample Copy of a compliant certificate of insurance has been provided with this letter.

Any additional expenses incurred by Whiteriver Construction caused by the subcontractor’s failure to comply with these requirements will be the responsibility of the subcontractor.

INSR ADDL SUBRLTR INSR WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACTNAME:

FAXPHONE(A/C, No):(A/C, No, Ext):

E-MAILADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBERPOLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

AUTHORIZED REPRESENTATIVE

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A(Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTEDCOMMERCIAL GENERAL LIABILITY $PREMISES (Ea occurrence)

CLAIMS-MADE OCCUR MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $

$PRO-POLICY LOCJECT

COMBINED SINGLE LIMIT$(Ea accident)

BODILY INJURY (Per person) $ANY AUTOALL OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS AUTOS

HIRED AUTOSNON-OWNED PROPERTY DAMAGE $AUTOS (Per accident)

$

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $WC STATU- OTH-TORY LIMITS ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2010 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 25 (2010/05)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE 08/04/2015

ABC BROKERPO BOX 1Farmington, NM 87499

AGENT INFORMATION

SUBCONTRACTOR APO BOX 2FARMINGTON, NM 87499

INSURANCE COMPANY INFO

A

X

X

X X 123456789 07/01/2015 07/01/2016 1,000,000100,0005,0001,000,0002,000,0002,000,000

A X X 123456789 07/01/2015 07/01/2016 1,000,000

A 123456789 07/01/2015 07/01/2016 1,000,0001,000,000

A

N

X 123456789 07/01/2015 07/01/2016 X1,000,000

1,000,0001,000,000

For Bidding Purposes

1 of 1#S388828/M388827

WHICON1Client#: 26683

JAS1 of 1

#S388828/M388827

subcontractor prequalification form final 08-04-2015 · yes no (a copy will be required if selected...

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