Subcontractor Pre-Qualification

Organization History

Number of years in business *

Number of years in business under current name *

Under what other or former names has your organization operated?

Number of Employees *

Number of Crews *

Licensing/Certifications

List all current licenses & associated license number

Federal Identification Number *

List all current Certifications

Experience

List all work that your organization normally performs with its own forces

List all current commitments of your organization, including contract values

Average contract value for current year *

Range of contract value for current year *

Average annual volume over last five years *

Range of contract value over last five years *

Projects Recently Completed in Virginia (List out of state projects only if necessary)

Completed Project

Title

Location

Scope(s) Performed

Contract Amount

Date Completed

Owner/GC

Contact Number

Claims and Suits

Has your organization failed to complete any project? *YesNo

Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers? *YesNo

Has your organization filed any lawsuits or requested arbitration with regard to construction contracts within the last five years? *YesNo

Has any officer or principal of your organization been an officer or principal of another organization when it failed to complete a construction contract within the last five years? *YesNo

Has your organization received any judgments, claims, arbitration proceedings or suits from second tier subcontractors for lack of payment within the last five years? *YesNo

If you answered Yes to any of the above questions, please give further details explaining *

Bonding

Is your organization bondable? *YesNo

Bonding Capacity

Bonding Company

Contact Person

Contact Number

Insurance

Is your organization insured? *YesNo

Insurance Company

Contact Person

Contact Number

Breeden Construction insurance requirements

Worker's Compensation

Statutory Employer's Liability:

$500,000 Per Accident
Bodily Injury by Accident

$500,000 Policy Aggregate
Bodily Injury by Disease

$500,000 Per Accident
Bodily Injury by Disease

Aggregate Limits of Liability

$1,000,000 Per Accident
Owned, non-owned & Hired Autos

Umbrellas or Excess Liability

$5,000,000

Comprehensive General Liability

Coverage A - Bodily Injury & Property

Damage Liability:
$1,000,000 Any One Occurance
Subject to Products Completed
Operations & General Aggregates
Fire Damage Liability:
$50,000 Any One Fire
Subject to General Aggregate

Coverage B - Personal & Advertising

Injury Liability:
$1,000,000 Any One Person
Subject to General Aggregate

Coverage C - Medical Payments

$5,000 Any One Person
Subject to General Aggregate

Automobile

Injury Liability:
$1,000,000 Per Accident
Owned, Non-owned & Hired Autos

Does your organization meet these requirements? *YesNo

If No, explain.

Financial

Projected revenue for current year *

Revenue for previous year *

Current backlog of work *

Current net worth *

Current credit limit *

Available credit limit *

Has your organization filed for Chapter 11 Bankruptcy protection within the last five years *YesNo

Has any officer or principal of your organization been an officer or principal of another organization that has filed for Chapter 11 Bankruptcy protection within the last five years? *YesNo

If you answered Yes to either of the last two questions, please provide further details

Safety and Environmental

Does your organization employ a safety coordinator? *YesNo

Contact Person

Contact Number

Does your organization require safety training for employees? *YesNo

Does your organization have a written safety program? *YesNo

Does your organization perform weekly safety meetings? *YesNo

Has your organization received any OSHA violations within the last five years? *YesNo

Has your organization received any environmental violations within the last five years? *YesNo

If you answered Yes to either of the last two questions, please add details further explaining, with details of the incident(s) and corrective actions taken to resolve the violation(s)ext

General Contractor/Owner References

Reference

Company Name

First Name

Last Name

Contact Number

Supplier References

Reference

Company Name

First Name

Last Name

Contact Number

Bank References

Reference

Company Name

First Name

Last Name

Contact Number

Certification of Accuracy

Form completed by

Title

I certify that the information contained in this form is accurate *

Yes

Save as Draft

Company Information

Organization History

Licensing/Certifications

Experience