New subcontractor?
Missing information may result in disqualification of consideration.
| Company Name: | Date: | ||||
|---|---|---|---|---|---|
| Street Address: | City/State: | ||||
| Zip Code: | Telephone: | Website: | |||
| UEI Number: | CAGE Code: | ||||
| Principal Contact: | Title: | ||
|---|---|---|---|
| Email Address: | Contact #: | ||
| Total Employees: | Field Employees: |
Has ownership changed in the last three years? (If yes, explain)
| Compliance Questions | Yes | No |
|---|---|---|
| Debarred/Suspended by public agency? | ||
| Officer debarred/suspended? | ||
| Pending judgments or claims? | ||
| Filed bankruptcy? | ||
| Construction lawsuits (last 3 years)? |
| License Type | License # | Issuing Agency |
|---|---|---|
| Metric | Current Year | Prior Year |
|---|---|---|
| DART Rate | ||
| TRC Rate | ||
| Total Fatalities (Col. G) | ||
| Annual Man-Hours |
| Project Title/Location: | |||||
|---|---|---|---|---|---|
| Value: | Start: | End: | |||
| Client: | |||||
| Description: | |||||
| Project Title/Location: | |||||
|---|---|---|---|---|---|
| Value: | Start: | End: | |||
| Client: | |||||
| Description: | |||||
| Question | Yes | No |
|---|---|---|
| Completed Basic NIST SP 800-171 Assessment? | ||
| Submitted to DoD SPRS? |
| Coverage Type | Limit Held ($) |
|---|---|
| General Aggregate ($2M Min) | |
| Each Occurrence ($1M Min) | |
| Worker's Comp ($1M Min) | |
| Automobile Liability ($1M Min) |
Please provide references below:
| Reference Company | Contact Name | Phone Number |
|---|---|---|
I hereby certify that the information submitted is true and complete.
| Name: | Signature: | (Digital below) | |
|---|---|---|---|
| Title: | Date: |
| Financial Review: | Safety Review: |