Contractor Prequalification Questionnaire

This questionnaire is used to evaluate contractors against minimum qualification criteria prior to contract award. Submission of this questionnaire does not constitute approval to perform work. All information is subject to verification. Provide accurate information; material misrepresentation may result in disqualification.

Section 1 — Company Information

Legal Company Name

DBA (if different)

Federal EIN

Year Established

Primary NAICS Code

Used to compare safety metrics to BLS industry averages

State(s) of Operations

Primary Business Address

Mailing Address (if different)

Primary Contact Name

Title

Phone / Email

Section 2 — Licensing and Credentials

List all current licenses held by the company or its personnel that are applicable to the work to be performed.

License Type	Issuing State / Authority	License Number	Expiration Date

Section 3 — Insurance Coverage

Attach a current ACORD 25 Certificate of Liability Insurance. Complete the fields below to summarize coverage.

General Liability Carrier

Policy Number

GL Per-Occurrence Limit

GL General Aggregate Limit

GL Policy Type

Occurrence Claims-Made

GL Policy Expiration Date

Workers' Comp Carrier

WC Policy Number

States Covered

WC Policy Expiration Date

Umbrella / Excess Limit

Auto Liability Limit

Additional Insured Endorsements:

ISO CG 20 10 (Ongoing Operations) available on request ISO CG 20 37 (Completed Operations) available on request

Section 4 — Safety Performance

Attach OSHA 300 Logs and 300A Summaries for the three most recent calendar years. Complete the table below.

Calendar Year	Total Hours Worked	Recordable Incidents	TRIR	Days Away Cases	DART Rate
20___
20___
20___
3-Year Average

Current EMR

Attach EMR letter from carrier / rating bureau (NCCI, WCIRB, etc.)

EMR Effective Date

Rating Bureau

NCCI / WCIRB / PCRB / NYCIRB / Other

OSHA Citations in Past 3 Years?

Yes (describe below) No

If yes, describe citation type, standard cited, and corrective actions taken

Section 5 — Client References

Provide two references from organizations for whom you have completed similar work within the past three years.

Organization Name	Contact Name and Title	Phone / Email	Type of Work Performed	Year(s)

Section 6 — Certification

I certify that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that material misrepresentation may result in disqualification. I authorize the requesting organization to verify the information provided, including contacting the references listed above and verifying insurance and licensing with the applicable carriers and agencies.

Authorized Signatory (print name and title)

Signature

Date