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Subcontractor Prequalification Questionnaire

Directions:

*Print out this page
*Fill-in the Blanks
*Submit on Company Letterhead
*Mail to Standard Builders, Inc.

Mail to: 
Standard Builders, Inc. 
Attn: Subcontractor Prequalification Processing Department
52 Holmes Road
Newington, CT 06111

(Submit on Company Letterhead)

(Must be complete for consideration – all information shall be treated confidentially)

1.       COMPANY DETAILS 
Firm's Name  ____________________________________________________________
Telephone No. ____________________________________________________________
Fax No. ____________________________________________________________
Street Address ____________________________________________________________
City ____________________________ State_________ Zip Code__________
Web Site ____________________________________________________________
President ____________________________________________________________
Vice President  ____________________________________________________________
Treasurer ____________________________________________________________
2.       COMPANY CONTACT
Person for Bids ____________________________________________________________
Title ____________________________________________________________
Email Address ____________________________________________________________
3.       FORM OF BUSINESS

(Check one)

 [ ] Sole Owner [ ] Partnership       [ ] Corporation
State of Registration ____________________________________________________________
Date of Registration ____________________________________________________________
Years in Business ____________________________________________________________

Other names your company has operated under

 ____________________________________________________________
4.       COMPANY MANAGEMENT

Under current management since

 (Date)_______________________________________________________
5.       PARENT COMPANY INFORMATION
Parent Company Name  ____________________________________________________________
Telephone # ____________________________________________________________
Street Address ____________________________________________________________
City ____________________________ State_________ Zip Code__________
6.      MINORITY BUSINESS INFORMATION
Is your company a qualified "Minority Business" (M/WBE)? [ ] Yes[ ] No
Where is your company registered? (City, State) _____________________________________
AFFIRMATIVE ACTION
Does your company have an Affirmative Action Plan for employees?  [ ] Yes      [ ] No
Does your company include training/orientation on sexual harassment in the workplace? [ ] Yes  [ ] No
  If Yes, explain:

_____________________________________________________________________________________________

______________________________________________________________________________________________

7.       NUMBER OF PERMANENT COMPANY PERSONNEL INCLUDING:
Administration: ________ Field Supervision:  ___________Engineering & Design: ________
Normal Field Construction Workers (per week): __________   Others: __________
List any labor organizations, which your company may have an agreement with: ___________________________________________
___________________________________________
___________________________________________

8.       HOW DOES YOUR COMPANY PERFORM THE WORK

     Indicate types of work performed through direct hire & types subcontracted. Please indicate percentages of Direct Hire 
        vs Subcontracted for each type: 

 

 

Types of work

 

Direct Hire

 

Subcontract

 

 

 

A.

B.

C.

D.

E.

 

 

 

 

F.

 

 

 

 

 

 

G.

 

 

 

 

 

 

H.

 

 

 

 

 

 

I.

 

 

 

 

 

 

J.

 

 

 

 

 

 

9.       ANNUAL DOLLAR VOLUME FOR THE PAST 3 YEARS

20___  $_________________   

 20 ___      $_______________    20__      $__________
10.  LARGEST JOB DURING 

THE LAST 3 YEARS     

 $____________
11.  TOTAL WORK IN PROCESS

(ie Current Work Load) 

 $____________ (Attach List of Current Work)
12.   BANK REFERENCES
Bank Name  ____________________________________________________________
Street Address ____________________________________________________________
City ____________________________ State_________ Zip Code__________
Contact Person ____________________________________________________________
Phone # ____________________________________________________________
Amount of Bank Line Credit $______________________
Secured [  ]  Yes     [  ]  No

12a. FINANCIAL STATEMENT
Include your company's latest balance sheet.

13.   BONDING REFERENCES
 Name  ____________________________________________________________
Street Address ____________________________________________________________
City ____________________________ State_________ Zip Code__________
Contact Person ____________________________________________________________
Phone # ____________________________________________________________
Total Bonding Capacity $____________________
Maximum Single Project Bonding Capacity $____________________
A.M. Best Rating of Bonding Company $____________________
U.S. Treasury Limit of Bonding Company $____________________

14.   LEGAL ISSUES
Are you now or have you ever been involved in any bankruptcy or reorganization proceedings? [  ]  Yes  [  ]  No
Are there judgments, claims or suits pending or outstanding against your company? [  ]  Yes  [  ]  No
Have you ever received notices of environment, health or safety violations from Regulatory agencies? [  ]  Yes  [  ]  No
Within the last five (5) years, have you failed to complete a contract? Unless such failure was caused by acts outside of your control? [  ]  Yes  [  ]  No

INSURANCE
List types of insurance carried in addition to that required by laws and state limits.
Limits:
Work Compensation:
Automobile Liability:
General Liability:
Excess Umbrella Liability:
Insurance Carrier:

15a.SAFETY PERFORMANCE HISTORY
Connecticut Workers Compensation Experience Modification Rate (as shown on Workers Compensation Insurance Policy) for the three (3) most recent years as follows: 20____  EMR:  ______    20___  EMR: _____      20___  EMR:  ______

Utilizing the OSHA No. 200 log for the last three years, the number of injuries and illnesses were recorded as follows:

 

 

20____

 

20____

 

20____

 

 

 

 

 

 

 

A.

Number of hours employees worked the year

 

 

 

 

 

B.

Number of restricted workday cases only

(extracted from Column 2 of OSHA log and not to include cases involving days away from work)

 

 

 

 

 

C.

Number of cases involving lost work days (Column 3 OSHA 200 log)

 

 

 

 

 

D.

Number of cases defined as recordable but without lost workdays. (Column 6 of OSHA 200 log)

 

 

 

 

 

E.

Number of fatalities (if yes, attached full explanation)

 

 

 

 

 

F.

Total number of cases for B, C D and E (not workdays)

 

 

 

 

 

G.

Recordable rate (injury x 200,000/man hours worked)

 

 

 

 

 

H.

Lost workday rate (rate x 200,000/man hours worked)

 

 

 

 

 

Attach the following documents to this submittal:
Copies of OSHA No. 200 log for the three most recent years.

Has your company been sited by OSHA in the past 3 years

  [  ] Yes       [  ]  No

If the answer is yes, explain

 __________________________________________________
__________________________________________________
15b. SAFETY POLICIES AND PROCEDURES

Do you have a documented safety policy and program?

 [  ] Yes    [  ]  No
 (Attached or forward copy with pre-qualification form)

Do you have a Safety Officer/Department in your company:

 [  ] Yes    [  ]  No

If yes, Name:

 ________________________________ 

Tel No. 

 ________________________________ 
Do you employ full time safety supervision on all job sites? [  ] Yes    [  ] No
Do you have a Personal Protective Equipment (PPE) Policy or Program? (ie: mandatory hard hats, safety glasses, etc?)    ] Yes    [  ] No
If yes, what does it cover? __________________________________________________
__________________________________________________
Does your Safety Program address all OSHA Standards as they apply to Contractors, (ie Hazardous Communication [29 FR 1926-59]) and Respiratory Protection (29 CFR 1926-103) and all of the requirements associated said Standards? [  ]  Yes     [  ]  No
Does your company have a Substance Abuse Program, which is designed to provide a drug free workplace? 
(enclose a copy of policy)		 [  ]  Yes     [  ]  No
Pre-employment screening? [  ]  Yes     [  ]  No
Random testing? [  ]  Yes     [  ]  No
For Cause testing? [  ]  Yes     [  ]  No
Comment on any areas of your company's safety program and policies that you feel will be appropriate in our evaluation.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
15c. SAFETY TRAINING
Do you require on-site supervision/foreman to have OSHA 30-hour Training Course? [  ]  Yes      [  ]   No
What type of safety orientation do you provide for new hires? 
                      [  ] Film      [  ] Slides      [  ] Handbook      [  ] Verbal      [  ] Other _________________
Topics included in Orientation: _________________________________________________
 __________________________________________________________________________
 __________________________________________________________________________
Specific topics: ______________________________________________________________
Is on-site supervision trained in?  [  ]  First Aid   [  ]  CPR
Are jobsite foreman's safety meeting required? [  ]  Yes  [  ]  No     
 Frequency:  _________
Are weekly toolbox safety meeting required? [  ]  Yes  [  ]  No     
 Frequency:  _________
Are regular safety/housekeeping audits conducted? [  ]  Yes  [  ]  No     
 Frequency:  _________

15d. SAFETY AUDITING AND INCIDENT INVESTIGATION
Do you have an accident investigation procedure?  [  ]  Yes      [  ]   No
Does senior management participate in accident investigations? [  ]  Yes      [  ]   No
Do you require your subcontractors to meet the same safety standard you employ? [  ]  Yes      [  ]   No
What level of management in your company received field safety reports?
______________________________________________________
16.   REFERENCES 
List the three (3) most recent contracts completed:

 A. Client Name 

 ____________________________________________________________
Street Address ____________________________________________________________
City ____________________________ State_________ Zip Code__________
Contact Person ____________________________________________________________
Phone # ____________________________________________________________
Type of Contract

Type of Work 

 ____________________________________________________________
% Volume ____________________________________________________________
Date Completed ____________________________________________________________

 B. Client Name 

 ____________________________________________________________
Street Address ____________________________________________________________
City ____________________________ State_________ Zip Code__________
Contact Person ____________________________________________________________
Phone # ____________________________________________________________
Type of Contract

Type of Work 

 ____________________________________________________________
% Volume ____________________________________________________________
Date Completed ____________________________________________________________

 C. Client Name 

 ____________________________________________________________
Street Address ____________________________________________________________
City ____________________________ State_________ Zip Code__________
Contact Person ____________________________________________________________
Phone # ____________________________________________________________
Type of Contract

Type of Work 

 ____________________________________________________________
% Volume ____________________________________________________________
Date Completed ____________________________________________________________

 

   16b. LIST OTHER REFERENCES AS DESIRED 

(attach separate sheet, if needed)

 ____________________________________________________________
____________________________________________________________

 

   17. REPRESENTATIVE PROJECTS 

Provide a list of representative projects and contacts

 ____________________________________________________________

(attach separate sheet, if needed)

 ____________________________________________________________
____________________________________________________________

SIGNATURE OF COMPANY OFFICER

____________________________________________________________________________
Signature                                                  Title                                              Date

 
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