Text Box: R-BROS CONTRACTORS, LLC SUBCONTRACTOR PRE-QUALIFICATION FORM PROJECT NAME: _______________________________ BID DATE: _______________ The bid your firm submitted for the project listed above is being considered. As part of our evaluation we request the following information: (When completed please fax to 866.376.1419. Questions may be directed to monica.chocan@rbroscontractors.com COMPANY INFO: COMPANYS LEGAL NAME: ___________________________________________________________ Address_____________________________________ Ph#______________________ Fax#_________________________ Is this a residential ad dress? Y___ N___ POINT OF CONTACT FOR BID: ________________________________________________________ NAME/.TITLE E-MAIL ADDRESS: ____________________________________ # OF EMPLOYEES _______ TYPE OF COMPANY (OTHER):______________________ SPECIAL GROUP: _____________ Circle one: Corporation Partnership Sole Proprietor (MBE/WBE/UNION, etc) FED ID #___________________________ or S.S. # __________________________ Owners or Major Stockholders___________________,_________________________,________________________, ________________________,__________________________,___________________________________ Time in business or DBA:_____________________ D&B# ____________________________ HAVE YOU BEEN IN BUSINESS UNDER ANY OTHER NAME IN PAST FIVE YEARS?__________ NAME OF BUSINESS______________________________________ & EXPLAIN ON SEPARATE PAPER IS THE FIRM NOW, OR HAS EVER BEEN INVOLVED IN BANKRUPTCY PROCEEDINGS? ________ IF YES, EXPLAIN ON SEPARATE PAPER.) ARE THERE ANY PENDING OR OUTSTANDING JUDGEMENTS, CLAIMS, OR SUITS? Y____ N____ (IF YES, EXPLAIN ON SEPARATE PAPER) THIS PROJECT: HAVE YOU SEEN THE ADDENDUMS ASSOCIATED WITH THIS PROJECT? IF SO, PLEASE LIST WHICH NUMBERS YOU HAVE REVIEWED:_________________________________________ DO YOU PLAN ON SUBCONTRACTING ANY OF YOUR WORK OUT? __________ IF SO, WHAT PART AND TO WHOM? ___________________________________________________________ DO YOU CURRENTLY HOLD A LICENSE IN THE STATE WHERE THIS JOB IS LOCATED? Y___ N___ HOW MANY PRODUCTION DAYS DO YOU HAVE ESTIMATED FOR THIS WORK? _____________ REFERENCES: BANK REFERENCE: ____________________________________________________________________ Name of Contact__________________________________ Ph# ___________________________ SUPPLIER REFERENCES: (Please list the subs/suppliers you plan to utilize for this project and have a history with) NAME ADDRESS PHONE 1._______________________ ___________________________ ________________________ 2._______________________ ___________________________ ________________________ 3._______________________ ___________________________ ________________________ GENERAL CONTRACTOR REFERENCES: (Please list projects your company y has done with similar scope.) NAME /PHONE PROJECT VALUE 1._______________________ ___________________________ ________________________ 2._______________________ ___________________________ ________________________ 3._______________________ ___________________________ ________________________ JOB HISTORY: PLEASE LIST THE 3 LARGEST JOBS IN THE PAST 3 YEARS: PROJECT NAME/G C CONTACT/PHONE # CONTRACT VALUE 1._______________________ ___________________________ ________________________ 2._______________________ ___________________________ ________________________ 3._______________________ ___________________________ ________________________ HAVE YOU EVER FAILED TO COMPLETE A JOB OR RECEIVED A NOTICE OF _______________ IF YES, PLEASE EXPLAIN ON SEPARATE PAPER. INSURANCE & SAFETY: INSURANCE AGENT: BONDING AGENT: NAME:___________________________________ NAME:__________________________________ COMPANY:_______________________________ COMPANY:______________________________ PH# _______________________ PH# ________________________________ IF REQUIRED, CAN A PAYMENT & PERFORMANCE BOND BE RECEIVED FOR THIS JOB? ___________ EXPERIENCE MODIFIER FOR LAST 3 YEARS: 2005________ 2004_________ 2003__________ DO YOU HAVE A SAFETY PROGRAM IN PLACE?__________ HAVE YOU RECEIVED AN OSHA CITATION IN THE LAST 3 YEARS UNDER ANY BUSINESS YOU’VE OPERATED UNDER?___________ IF YES, EXPLAIN ON BACK OR ATTACH A COPY NOTICE: PLEASE SEE EXHIBIT D; TO INSURE YOUR INSURANCE MEETS OUR REQUIREMENTS PRIOR TO BIDDING. A CURRENT AND PROPER CERTIFICATE MUST BE ATTACHED TO THIS QUALIFICATION FORM FOR YOU TO BE CONSIDERED FOR THIS JOB. IF YOU DO NOT HAVE THESE LIMITS CURRENTLY, ARE YOU ABLE TO OBTAIN THE NECESSARY INSURANCE LIMITS AS PER OUR INSURANCE EXHIBIT ATTACHED? Y____ N____ (If no, list reason on separate paper) I certify that all the above information is true and correct and hereby authorize R-BROS CONTRACTORS, LLC to perform a background check on my company to include a credit check with the supplier, job, and contractor references listed above. _____________________________ ____________ SIGNATURE OF OWNER DATE EXHIBIT D INSURANCE COVERAGE REQUIREMENTS & PROCEDURES PLEASE FORWARD A COPY OF THESE INSURANCE REQUIREMENTS TO YOUR INSURANCE AGENT TO ENSURE COMPLIANCE. NO PAY APPLICATIONS WILL BE PAID UNLESS CORRECT INS. CERTIFICATE IS ON FILE WITH US! Pursuant to Article 19 of the Subcontract Agreement, Subcontractor shall maintain at least the following insurance coverage’s in addition to any other coverage’s or any great limits required by the Contract Documents; COMMERCIAL GENERAL LIABILITY: $1,000,000 per occurrence $2,000,000 General Aggregate $2,000,000 Product-Comp/OP Agg including Per Project Aggregate This policy shall be on a form reasonably acceptable to Contractor & Owner, shall include a Waiver of Subrogation, and be endorsed to include the Contractor & Owner as additional insured, and shall include the following coverage's: 1) Premises / operations 2) Independent agents 3) Completed operations for a period of two years following the acceptance of Contractor’s Work 4) Broad form contractual liability specifically in support of, but not limited to, the indemnity sections of the Contract Agreement. 5) Broad form property damage. 6) Personal injury liability with employee and contractual exclusions removed 7) Delete exclusions relative to collapse, explosion, and underground property damage hazards. 8) Additional insured endorsement CG 2010 1185 or endorsement with equivalent wording. BUSINESS AUTO COVERAGE: $1,000,000 combined single limit, each occurrence; bodily injury and property damage. This policy shall be on a standard form written to cover all owned, hired, and non-owned automobiles. The policy shall be endorsed to include the Contractor & Owner as additional named insured and shall include a Waiver of Subrogation. WORKER’S COMPENSATION: – statutory limits Employer’s liability limits: $500,000 each accident $500,000 disease – policy limit $500,000 disease – each employee This policy shall include a Waiver of Subrogation in favor of the Owner and R-BROS CONTRACTORS, LLC UMBRELLA EXCESS LIABILITY INSURANCE: $1,000,000 per occurrence $1,000,000 aggregate NOTICE OF CANCELLATION OR CHANGE: If any insurance coverage required above is or is to be canceled or changed in any way so as not to satisfy the requirements above, Subcontractor shall provide, and Subcontractor shall require its Insurer to provide, notice in writing to the Contractor and its agents thirty (30) days in advance of the cancellation or change. BUILDERS RISK INSURANCE: If Builder’s Risk insurance purchased by Owner or Contractor provides coverage for Subcontractor for loss or damage to Subcontractor’s work, Subcontractor shall be responsible for the insurance policy deductible amount applicable to damage to Subcontractor’s work and/or damage to other work caused by Subcontractor. R-BROS CONTRACTORS, LLC, 8615 S. 22nd Place Phoenix, Arizona 85042   NEEDS TO BE LISTED AS CERTIFICATE HOLDER & ADDITIONAL NAMED INSURED WITH SPECIFIC PROJECT NOTED. INSURANCE COMPANY MUST HAVE AN AM BEST RATING OF A7 OR BETTER. SHOW THE CANCELLATION DATE AS 30 DAYS. PLEASE MAIL AN ADDENDUM ALONG WITH YOUR INS.CERT. SHOWING ANY EXCLUSIONS AND SIGNED BY YOUR AGENT.


EXHIBIT D

 

INSURANCE COVERAGE REQUIREMENTS & PROCEDURES

 

PLEASE FORWARD A COPY OF THESE INSURANCE REQUIREMENTS TO YOUR INSURANCE AGENT TO ENSURE

COMPLIANCE.  NO PAY APPLICATIONS WILL BE PAID UNLESS CORRECT INS. CERTIFICATE IS ON FILE WITH US!

 

Pursuant to Article 19  of the Subcontract Agreement, Subcontractor shall maintain at least the following insurance coverage’s in addition

to any other coverage’s or any great limits required by the Contract Documents;

 

COMMERCIAL GENERAL LIABILITY:

$1,000,000      per occurrence

$2,000,000      General Aggregate

$2,000,000  Product-Comp/OP Agg  including Per Project Aggregate

 

This policy shall be on a form reasonably acceptable to Contractor & Owner, shall include a Waiver of Subrogation, and be endorsed to

include the Contractor & Owner as additional insured, and shall include the following coverages:

 

1) Premises / operations

2) Independent agents

3) Completed operations for a period of two years following the acceptance of Contractor’s  Work

4) Broad form contractual liability specifically in support of,  but not limited to, the indemnity sections of  the Contract Agreement.

5) Broad form property damage.

6) Personal injury liability with employee and contractual exclusions removed

7) Delete exclusions relative to collapse, explosion, and underground property damage hazards.

8) Additional insured endorsement CG 2010 1185 or endorsement with equivalent wording.

 

BUSINESS AUTO COVERAGE:

$1,000,000 combined single limit, each occurrence; bodily injury and property damage

This policy shall be on a standard form written to cover all owned, hired, and non-owned automobiles.  The policy shall be endorsed to

include the Contractor & Owner as additional named insured and shall include a Waiver of Subrogation.

 

WORKER’S COMPENSATION: – statutory limits

Employer’s liability limits:

$500,000   each accident

$500,000   disease – policy limit

$500,000   disease – each employee

This policy shall include a Waiver of Subrogation in favor of the Owner and R-BROS CONTRACTORS, LLC

 

UMBRELLA EXCESS LIABILITY INSURANCE:

$1,000,000 per occurrence

$1,000,000 aggregate

 

NOTICE OF CANCELLATION OR CHANGE:

If any insurance coverage required above is or is to be canceled or changed in any way so as not to satisfy the requirements above,

Subcontractor shall provide, and Subcontractor shall require its Insurer to provide, notice in writing to the Contractor and its agents thirty

(30) days in advance of the cancellation or change.

 

BUILDERS RISK INSURANCE:

If Builder’s Risk insurance purchased by Owner or Contractor provides coverage for Subcontractor for loss or damage to Subcontractor’s

work, Subcontractor shall be responsible for the insurance policy deductible amount applicable to damage to Subcontractor’s work and/or

damage to other work caused by Subcontractor.

 

R-BROS CONTRACTORS, LLC, 8615 S. 22nd Place Phoenix, Arizona 85042

 

 NEEDS TO BE LISTED AS CERTIFICATE

HOLDER & ADDITIONAL NAMED INSURED WITH SPECIFIC PROJECT NOTED.

 

INSURANCE COMPANY MUST HAVE AN AM BEST RATING OF A7 OR BETTER.

 

SHOW THE CANCELLATION DATE AS 30 DAYS.  PLEASE MAIL AN ADDENDUM ALONG WITH YOUR INS.CERT.

SHOWING ANY EXCLUSIONS AND SIGNED BY YOUR AGENT.