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GBC SUBCONTRACTOR PREQUALIFICATION FORM
Company Information
Company Name
Company Type
Company Type
Corporation
Sole Propriaty
LLC
Legal Entity's Name
Year Established
Physical Address
FED TAX ID
Union AffiLiation
Union
Non Union
CA License
Phone Number
Website
Is This Company Bondable?
Yes
No
Bonding Rate
Bonding Company
Single Project Limit
Company Primary Contacts
I. Estimating Dept
Name
Direct Phone Number
CELL
Email
II. Company Primary Point of Contact
Name
Direct Phone Number
CELL
Email
III. Accounting
Name
Direct Phone Number
CELL
Email
Geographic Areas & Trades Performed
Primary Trades / CSI Scope Performed
Primary Geographic Regions Serviced
Other Regions / States Serviced
Active Licenses In Other States
Insurance
* All Subcontractor / Vendor insurance Certificates must comply with the project specific insurance requirements for the stipulated certificate holder and any listed additional insured parties.
Insurance Company
Primary Contact
Phone
Email
Policy
Each Occurance
Aggregate
Each Occurance
Aggregate
Combined Single Limit
Active Workers Comp Insurance Policy
Litigation / Safety Status
Has this company ever defaulted and/or failed to complete or been ternminated on a contract to perform work? If Yes, Please provide clarification
Yes
No
Clarificaion
Has this company ever gone through a Bankruptcy or Reorganization? If Yes, Please Provide Clarification
Yes
No
Clarification
This Companies E.M.R. Status Over Past 3 Years: (Experience Modification Rate Provided By Your ins. broker)
2020
2021
2022
List The Number Of Osha Violations Over Past x3 Years
2020
2021
2022
Does this company have an active written safety program?
Yes
No
Provide The Contact Information For This Companies Safety Officer?
Authorization
I,
am the
of the above listed company and am qualified to make this certification o behalf of the Company. I certify, based upon my knowledge and belief, that the information supplied in this form is complete and correct. I authorize Global Building Corporation - GBC to verify the above information as needed.
Signature
Title
Print Name
Date
MM slash DD slash YYYY
File
Max. file size: 600 MB.
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