FORM 107 – Subcontractor Pre-Qualification

SUBCONTRACTOR PRE-QUALIFICATION FORM

Missing information may result in disqualification of consideration.

BACKGROUND

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)?

LICENSES & SCOPES OF WORK

LICENSES HELD BY FIRM

License Type	License #	Issuing Agency

CSI DIVISIONS (PART 1)

SAFETY PERFORMANCE

CSI DIVISIONS (PART 2)

Div 22 Plumbing

Div 26 Electrical

Div 23 HVAC

Div 31 Earthwork

Div 21 Fire Suppr.

Div 33 Utilities

SAFETY METRICS (OSHA 300)

Metric	Current Year	Prior Year
DART Rate
TRC Rate
Total Fatalities (Col. G)
Annual Man-Hours

PAST PERFORMANCE

Project Title/Location:
Value:	Start:	End:
Client:
Description:

Project Title/Location:
Value:	Start:	End:
Client:
Description:

CYBERSECURITY ASSESSMENT

Question	Yes	No
Completed Basic NIST SP 800-171 Assessment?
Submitted to DoD SPRS?

INSURANCE COVERAGE MINIMUMS

Coverage Type	Limit Held ($)
General Aggregate ($2M Min)
Each Occurrence ($1M Min)
Worker's Comp ($1M Min)
Automobile Liability ($1M Min)

FINANCIALS & REFERENCES

Please provide references below:

Reference Company	Contact Name	Phone Number

CERTIFICATION & OFFICIAL USE

I hereby certify that the information submitted is true and complete.

Name:		Signature:	(Digital below)
Title:		Date:

FOR OFFICIAL USE ONLY

Financial Review:

Safety Review:

Pacific Rim Portal

PacificRIM

BACKGROUND

PacificRIM

LICENSES HELD BY FIRM

CSI DIVISIONS (PART 1)

PacificRIM

CSI DIVISIONS (PART 2)

SAFETY METRICS (OSHA 300)

PacificRIM

PacificRIM

PacificRIM

PacificRIM

PacificRIM

FOR OFFICIAL USE ONLY