SUBCONTRACTORS PREQUALIFICATION FORM Please fill out the form below and click submit when completed. Step 1 of 7 14% Company Name*Email* Company Address*Phone*FaxType of work: (Please use space provided to explain in further detail in specific work perforemed by your company) General Construction Details: Earthwork & Landscaping Details: Concrete Details: Mansory Details: Steel Fabrication or Erection Details: Carpentry Details: Glass & Glazing Details: Doors/Frames/Hardware Details: Finishes(Drywall, Wall Finishes, Flooring, etc.) Details: Building Specialties or Building Equipment Details: Elevators Details: Instrumentation & Controls Details: Specialty Gases Details: Special Systems (CCTV, Radio Hazardous Production Material, Smoke Detection, etc.) Details: Plumbing Details: Process Details: Mechanical Details: Fire Protection Details: Electrical Details: Other Details: Organization1. How many years has your organization been in business as a contractor?2. How many years has your organization been in business under its present business name?a) Under what other or former names has your organization operated?3. If your organization is doing business as a corporation, provide the following information:a) Date of incorporation:b) State of incorporation:c) Names of officers of the corporation: (President, Treasurer, Other)If your organization is a partnership, provide the following information:a) Date of organization:b) Type of partnership ( if applicable):c) Names of general partner(s):If your company is individually owned, provide the following:a) Date of organization:b) Name of Owner: Licensing Please provide Contractors License for the state(s) in which this company performs business.References Trade References (Name & Phone Number):a)b)c)Bank References (Name & Phone Number):Surety:a) Name of Bonding Company:b) Name and Address of Agent:Experience 1. On a separate sheet(s) please provide your companies experience for the area of work you perform. With each reference listed please furnish the following: a) Location of Work b) Description of Work c) Owner Reference d) Architect Reference e) Contract Start & Finish Dates f) Contract Amount ♦ Note: Please separate references in chronological order by most recent date. Safety: Please complete the attached “Subcontractor Safety Evaluation Questionnaire” Subcontractor Safety Evaluation QuestionnaireCompany Name:Company Address:PhoneFaxPerson Completing the Questionnaire:Title:Person Responsible for all Safety at your Company:Title:Date Prepared:Are you directly contracted to CMI or someone else? CMI Someone else If some else, who?1 (a). Please list your firm’s workers’ compensation experience modification rate for the past three (3) years (or rating periods) in all states in which your firm has been rated.YearState(s)Average1 (b). Please list your firm’s interstate (ie. NCCI) experience modification rate, if any, for the past three (3) years.YearRatingNumber of injuries and illnesses for your entire company. Use your OSHA 300A logs from the past three (3) years to complete this section.YearYearYeara) Number of Lost Workday CasesYears (separated in comma Ex. 2014, 2015, 2016):b) Number of Restricted Day CasesYears (separated in comma Ex. 2014, 2015, 2016):c) Number of Medical Only Cases1Years (separated in comma Ex. 2014, 2015, 2016): d) Number of FatalitiesYears (separated in comma Ex. 2014, 2015, 2016):1Columns #6 and #13 of the OSHA 300A Log.Attach a copy of your OSHA 300A logs for the previous three (3) years. Drop files here or Accepted file types: jpg, png, pdf. 3. Employee actual hours worked for each of the last three (3) years (do not include any nonwork time, even though it was paid, ie. sick leave, vacation) YearManhours 4. Are accident reports (ie. OSHA 300A log) and report summaries sent to the following individuals?Field Superintendents Monthly Quarterly Annually Not Sent Vice President of Construction Company Monthly Quarterly Annually Not Sent President of Construction Company Monthly Quarterly Annually Not Sent Attach two (2) examples of incident/accident case summaries used by your company. Drop files here or Accepted file types: jpg, png, pdf. 5. How often do you hold site safety meetings for field supervisors? Weekly Bi-weekly Monthly Quarterly Semi-annually Annually Never Attach two (2) copies of previous agendas used during safety meetings for supervisors. Drop files here or Accepted file types: jpg, png, pdf. 6. Does your firm conduct jobsite safety inspections?YesNoIf yes, who conducts this inspection? (Name/Title) How often?Attach two (2) copies of recent and completed site inspections from any project. Drop files here or Accepted file types: jpg, png, pdf. 7. How frequently are summaries of OSHA incidence rates prepared for each of the following?Incident Rates Totaled for Entire Company Monthly Annually Not Presented at this Level Incident Rates Totaled by Project Monthly Annually Not Presented at this Level Incident Rates Totaled by Superintendents Monthly Annually Not Presented at this Level Incident Rates Totaled by Foremen Monthly Annually Not Presented at this Level Attach two (2) complete examples of OSHA incident rate summaries. Drop files here or Accepted file types: jpg, png, pdf. 8. Does your firm have a written safety plan, also known as an Injury and Illness Prevention Program (IIPP)? Yes No Attach a copy of your firm’s safety plan/Injury Illness and Prevention Plan (IIPP) Drop files here or Accepted file types: jpg, png, pdf. Does your firm have a safety orientation program for new hires? Yes No If yes, does this include instruction on the following? Head Protection Yes No N/A Eye Protection Yes No N/A Hearing Protection Yes No N/A Respiratory Protection Yes No N/A Fall Protection Yes No N/A Scaffolding Yes No N/A Perimeter Guarding Yes No N/A Housekeeping Yes No N/A Fire Protection Yes No N/A First Aid Facilities Yes No N/A Overall Code of Safe Work practices Yes No N/A Injury Reporting Yes No N/A Emergency Procedures Yes No N/A Signs, Barricades, Flagging Yes No N/A Electrical Safety Yes No N/A Rigging and Crane Safety Yes No N/A Attach two (2) separate examples of orientations from two (2) different projects. Drop files here or Accepted file types: jpg, png, pdf. 10. Do you have a training program for newly hired or promoted supervisors? Yes No If yes, does this include instruction on the following?Safe Work Practices Yes No N/A Safety Supervision Yes No N/A Toolbox/Tailgate Meetings Yes No N/A Emergency Procedures Yes No N/A First Aid/CPR Procedures Yes No N/A Accident Investigation Yes No N/A Fire protection and Prevention Yes No N/A New Worker Orientation Yes No N/A Attach two (2) samples of materials used at supervisor training. Drop files here or Accepted file types: jpg, png, pdf. 11. How frequently do your supervisors hold toolbox/tailgate safety meetings?DailyYesNoWeeklyYesNoBi-WeeklyYesNoMonthlyYesNoLess often, as neededYesNoAttach two (2) copies of recent toolbox/tailgate talks. These may be in outline form. Drop files here or Accepted file types: jpg, png, pdf. 12. Are supervisor’s/superintendent’s safety records and/or behavior specifically rated or measured on their performance reviews?YesNoPlease attach a copy of the evaluation criteria for supervisors that includes safety.Accepted file types: jpg, png, pdf.Has your company been inspected/cited by OSHA for a safety or health violation within the last three years?YesNoIf yes, please explain: Printed Name First Last Date submitted: Date Format: MM slash DD slash YYYY Please upload signature:Accepted file types: jpg, png, pdf.Title This iframe contains the logic required to handle Ajax powered Gravity Forms.