Subcontractors / Vendors

Subcontractors Pre-Qualification Form

Please complete the form below to pre-qualify with LeLack Construction.

* - required fields

Business Section

Legal Business Name*

Project, if applicable
Street Address
Street Address 2
City
City 2
State
State 2
Zip
Zip 2
Principal Contact
Years in Business
Phone
Fax
Contact Email*
Company Website

Have you failed to complete awarded work or been terminated for cause? Do you have any judgments, claims, arbitrations, suits or liens currently against your organization? Had any bankruptcies or reorganizations? *
Yes No * If yes, please explain below:

Safety Section

Enter your Experience Modification Rate(EMR) for the last three years:

2007 (EMR) Rate
2006 (EMR) Rate

2005 (EMR) Rate
Number of OSHA Recordable incidents over the prior three years

(Data available at www.osha.gov)

Do you have a written safety program? *
Yes No

Project Information Section

Enter data from three most recent completed fiscal years:

Year

Max. Contract Value
Completed

Annual Company
Revenue

Current Year Company
Workload

List license numbers in jurisdictions in which you company is legally qualified to work:

State

License Number

Expiration

Insurance and Bonding Section

Do you currently carry, or can you obtain the following insurance coverage? *

Worker's Compensation Statutory Maximum at Project Site Location   Yes No
General Liability $1,000,000    Yes No
Automobile Liability $1,000,000   Yes No
Employer Liability $1,000,000   Yes No

Bonding
Company

Total Bonding
Capacity $

Current Available
Bonding Capacity $

Reference Section

Project References (Within Last Three Years)

Project Name
Project Location (City, State)
Completion Date (MM/YY)
Your Firms Approximate Contract Amount
Project General
Contractor
GC Contact and Telephone Number
Briefly Describe Work Performed By Your Firm
Project Name
Project Location (City, State)
Completion Date (MM/YY)
Your Firms Approximate Contract Amount
Project General
Contractor
GC Contact and Telephone Number
Briefly Describe Work Performed By Your Firm
Project Name
Project Location (City, State)
Completion Date (MM/YY)
Your Firms Approximate Contract Amount
Project General
Contractor
GC Contact and Telephone Number
Briefly Describe Work Performed By Your Firm

Scope Of Work Section

Confidential Note:

The information supplied by the undersigned in this document is intended only for the use of LeLack Construction.

The undersigned certifies that the information provided herein is a clear and accurate representation of this organization. Information Supplied by:

Name
Title
Date

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Areas we Service: