Company Primary Contacts
I. Estimating Dept
II. Company Primary Point of Contact
Geographic Areas & Trades Performed
* All Subcontractor / Vendor insurance Certificates must comply with the project specific insurance requirements for the stipulated certificate holder and any listed additional insured parties.
Litigation / Safety Status
This Companies E.M.R. Status Over Past 3 Years: (Experience Modification Rate Provided By Your ins. broker)
List The Number Of Osha Violations Over Past x3 Years
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.
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