PRE-QUALIFICATION FORM


Date:

To select the date please click on the right corner and then use the date picker

COMPANY:

Company Name:

Address:

Phone Number:....Fax Number:

Contact Name:

Contact Email:

Type of company:

Date Formed:

Federal tax ID#:

LABOR:

Does the company have any union agreements? YesNo

MBE/WBE/SBE/DBE CERTIFICATION:

Is your firm certified? YesNo

If yes, please check all that apply:MBEWBESBEDBEDVBELSDBEOTHER

Certifying Agency (s):................................................Certification Number (s)


INSURANCE:

Acknowledge you have the following minimum coverage: YesNo

Workers Compensation Insurance: Statutory Coverage in state where work is being done.
100,000 each accident
100,000 disease each employee
500,000 disease policy limit

General Liability:
1,000,000 each occurrence.
2,000,000 aggregate.
1,000,000 products and completed operations.

Auto:
1,000,000 any auto, hired and non owned.

Umbrella or Excess Liability:
1,000,000 each occurrence
1,000,000 aggregate

Insurance company address:

Agent Name:

Agent phone: