Subcontractor Pre-Qualification

1. Bidder Info

Bidding Company *

CSI Code(s) / Trade

Street Address Line 1 *

Street Address Line 2

City *

State *

Zip Code *

First Name *

Last Name *

Email *

Office Phone *

Cell Phone

Type of Firm

CorporationPartnershipSole Owner

Status of Bidding Company

WBEMBEDBENot Applicable

In which categories does the firm intend to bid?

Year Incorporated / Founded

State Where Incorporated / Founded *

How many years have you operated under the above name?

EMR
(Experience Modification Rate)

TRIR
(Total Recorded Incident Rate)

How many years under present ownership?

Is your firm presently covered by an A-rated or above insurance company for the following coverage?

Workers Comp Comprehensive Liability

Single Job Limit

Aggregate Limit

Bonding Company

Address

Contact Name & Phone

Firm's business volume for the last year.

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