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New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
1.0 ORGANIZATION INFORMATION:
1.1 GENERAL INFORMATION
Company Name:
Mailing Address
City State: Postal Code:
Main Telephone: Fax:
Office Address
(if different from
above)
City State: Postal Code:
1.2 ENTITY (please check one only)
Corporation
Partnership
Sole Proprietor
Joint Venture
Other Please Specify:
1.2.1 If your organization is a Corporation, answer the following:
Date of Incorporation:
State of Incorporation:
President’s Name:
Secretary’s Name:
Treasurer’s Name:
1.2.2 If your organization is a Partnership, answer the following:
Date of organization:
Type of Partnership:
Name(s) of General Partners:
1.2.3 If your organization is a Sole Proprietorship, answer the following:
Date of organization:
Name of Owner:
1.2.4 If your organization is other than listed above, describe it below:
Rev. 1 – 3 DEC 2008
Page 1 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
1.2.5 How many years has your organization been in business as a contractor?
1.2.6 How many years has your organization been in business under this name?
1.2.7 Under what other former names has your organization operated?
1.2 FEDERAL TAX ID NUMBER:
1.3 DISADVANTAGED BUSINESS STATUS (please check one):
Does your company have a Minority Certification? Yes No
If yes, please check all that apply
Women Business Enterprise (WBE)
Minority Business Enterprise (MBE)
Small Disadvantaged Business (SBA 8(a))
Veteran-Owned Business (VOB)
1.4 OTHER COMPANY ENTITIES
Please list any other company names that you perform work under, are affiliated with, are a subsidiary of, or have
business relationships with:
2.0 CAPABILITIES:
Please check all that apply:
General Contractor
Sub-contractor
Architect/Engineer
Consultant
Other Please specify:
Please check the categories of work that you are qualified to perform with your own personnel:
01000 Gen. 03010 Concrete 09800 Special
07270 Firestopping 12000 Furnishings
Contractor Slabs Coatings
01120 Rental Eqpt. 03050 Cnc Pumping 07400 Roofing/Siding 09900 Painting 12300 Casework
01295 Waste 03100 Cnc 12500 Window
07410 Wall Panels 09950 Wall Covering
Removal Foundations Treatments
03110
01410 Test/Inspection 07570 Traffic Coatings 10000 Misc Specialties 13000 Cleanroom Const
Curbs/Formwork
10150 13038 Controlled Temp
01500 Temp Facilities 03200 Reinforcing 07600 Flashing
Compratmnts/Cbcls Rm
Rev. 1 – 3 DEC 2008
Page 2 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
01520 07700 Roof
03300 CIP Concrete 10200 Louvers/Vents 13120 Pre-Eng Structures
Trailers/Containers Acs/Speclts
01540 10260 Wall/Crnr
03305 Cutting/Drilling 07810 Skylights 13125 Seating/Bleachers
Scaffold/Platforms Guards
03400 Precast
01560 Barriers 07900 Caulk/Sealants 10270 Access Flooring 13800 Bldg Automtn Sys
Concrete
01740 Const. 03430 Precast
08800 Glass/Glazing 10350 Flagpoles 14200 Elevators
Cleaning Erection
02090 Asb/Ld Abtmnt 04200 Masonry 08100 DF&H 10415 Display Boards 14400 Lifts
02200 Sitework 04400 Stone 08200 Wood Doors 10430 Signage 14500 Material Hndlg Sys
04600
02220 Demolition 08300 Overhead Doors 10500 Lockers 15000 Process Piping
Hoisting/Rigging
10522 Fire
02240 Dewatering 05130 Steel Erection 08400 Strfrnt/Entrances 15240 Noise/Vibtn Control
Ext/Cabinets
05210 Structural
02250 Shoring 08500 Windows 10536 Awnings 15250 Mech Insulation
Steel
02300 Earthwork 05300 Metal Decking 08700 Door Hardware 10600 Partitions 15300 Fire Protection
02315 Excavation 05500 Misc Metals 08900 Curtainwall 10800 Toilet Accessrs. 15400 Plumbing
02350 Piles/Caissons 05580 Sheet Metal 09200 Lath/Plaster 11130 AV Equipment 15500 HVAC
02354 Fntns/Wtr 05700 Ornamntl
09250 Drywall 11132 Projctn Screens 15850 Air Handling
Featrs Metals
06100 Rough
02400 Boring 09300 Ceramic Tile 11160 Ldng Dock Eqt 15890 Ductwork
Carpentry
06200 Finish
02500 Paving 09400 Terrazzo 11200 Water Trtmnt Eq 15970 Instrmntn/Controls
Carpentry
11400 Food Srvc
02580 Pavement Mrkg 06220 Millwork 09500 Acstical Ceilings 15990 Mech Test/Balance
Equipt
06400 Arch
02585 Bridges 09550 Wood Flooring 11450 Appliances 16000 Electrical
Woodwork
02600 07100
09600 Stone Flooring 11480 Athletic Eqpmnt 16310 Sbstns/Swithgears
Site/TmpUtilities Water/Dampprfg
02800 Site Concrete 07200 Bldg Insulation 09650 Resilient Flrng 11482 Scoreboards 16720 Alarm Systems
02820 Fences/Gates 07240 EIFS 09680 Carpet 11600 Laboratory Eqt 16740 Tele/Data Systems
02900 Landscaping 07250 Fireproofing 09700 Resinous Flrng 11860 Traffic Cntrl Eqt Other:
3.0 GEOGRAPHICAL WORK AREAS
List the states in which you perform work:
Do these areas require licenses? Yes No
If yes, please list:
4.0 LABOR RELATIONS
4.1 Labor Affiliation:
Please select only one:
Union List Agreements your organization is signatory to:
Collective Bargaining Union Local Location Expiration date
Agreement
Non-Union
Merit Shop
Rev. 1 – 3 DEC 2008
Page 3 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
4.2 Staffing:
Office:
Field:
Trades people:
5.0 REFERENCES (use the space provided or if more room is required, attach additional documents):
5.1 Trade References:
Company Name:
Mailing Address
City State: Postal Code:
Contact: Email Address:
Telephone: Fax:
Company Name:
Mailing Address
City State: Postal Code:
Contact: Email Address
Telephone: Fax:
5.2 Bank References:
Bank Name:
Mailing Address
City State: Postal Code:
Contact: Email Address
Telephone: Fax:
Bank Name:
Mailing Address
City State: Postal Code:
Contact: Email Address
Telephone: Fax:
5.3 Surety:
Name:
Mailing Address
City State: Postal Code:
Contact: Email Address:
Telephone: Fax:
Rev. 1 – 3 DEC 2008
Page 4 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
5.4 Insurance :
Name:
Mailing Address
City State: Postal Code:
Contact: Email Address:
Telephone: Fax:
6.0 PROJECT REFERENCES:
Please provide information on the last three projects worked:
6.1 Project Name: Location:
Owner: Contact: Phone:
GC or CM: Contact: Phone:
Your Contract Value: Date Completed:
6.2 Project Name: Location:
Owner: Contact: Phone:
GC or CM: Contact: Phone:
Your Contract Value: Date Completed:
6.3 Project Name: Location:
Owner: Contact: Phone:
GC or CM: Contact: Phone:
Your Contract Value: Date Completed:
7.0 FINANCIAL INFORMATION:
7.1 Annual Volume of work for last three years:
Enter Year:
20 20 20
$ $ $
7.2 Value of Projects underway or projected for this year:
$
7.3 Financial Statements:
Attach to this document your organization’s most recent, preferably audited, Balance Sheet and Income
Statement.
Rev. 1 – 3 DEC 2008
Page 5 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
7.4 Bonding Capacity
Is your company presently bonded or have the capability to become bonded? Yes No
What is your Bonding Capacity?
Maximum Bond Limit:
7.5 Project Bidding Information:
Please provide your bidding limits: From (Min $) to (Max $)
Do you subcontract any portion of your work? Yes No
If yes, please list portions of work usually subcontracted
This Form was completed by:
Submitted By: Date:
Signature Title
Telephone:
Fax:
Email Address:
Please return the completed form to:
Richard Drury
New England Construction Co., Inc.
293 Bourne Ave
Rumford, RI 02916
Rev. 1 – 3 DEC 2008
Page 6 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
Health, Safety and Environmental Information (HSE)
Please fill-out completely as possible (please print or type)
Company Name:
Primary Services Performed:
In general, your firm’s Health, Safety & Environmental (HSE) performance for the last three years will be considered in this
pre-qualification evaluation with emphasis given to the most recent year’s performance.
Please provide the following HSE related information:
1. List your firm’s interstate or intrastate (if applicable) Experience Modification Rate (EMR) for the three most recent
years, as evidenced in Workman’s Compensation Insurance premiums:
Year: Year: Year:
Rate: Rate: Rate:
For the EMR to be satisfactory, the rate established by the National Council on Compensation Insurance (NCCI) or
state rating bureau (if applicable) should be no greater than 1.2;
Are these rates: InTER-state/national average or InTRA-state/provincal
Please check this box if your company has less than the minimum number of employees required by law to carry
workers’ compensation insurance or if your company does not have an EMR. (If checked, please provide a letter
from your Insurance Company or WCB stating this)
Is your company self-insured for Workers Compensation claims? Yes No
2. Fill in the following information for the last three available years. (Use your last three annual OSHA 200 or 300 Logs)
A. Number of Total (OSHA/BLS) Recordable Cases (Total Col. 1, 2, 6, 8, 9 & 13 on OSHA 200 Log,/ Total Col. G, H, I, J, on
OSHA 300 Log):
Year: Year: Year:
Rate: Rate: Rate:
B. Number of Restricted Work Activity Cases (Subtract Col. 3 from Col. 2 & subtract Col. 10 from Col. 9 then add the
two results together on OSHA 200 Log,/ Col. i on OSHA 300 Log):
Year: Year: Year:
Rate: Rate: Rate:
Rev. 1 – 3 DEC 2008
Page 7 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
Health, Safety and Environmental Information (HSE)
C. Number of Lost Workday Cases (Col. 3 & 10 on OSHA 200 Log,/Col. J on OSHA 300 Log):
Year: Year: Year:
Rate: Rate: Rate:
D. Number of Fatalities (Col. 1 & 8 on OSHA 200 Log,/ Col. G on OSHA 300 Log):
Year: Year: Year:
Rate: Rate: Rate:
If your company experienced a work-related fatality during this period, please provide a brief description of the
causes and corrective actions taken.
3. Employee hours worked (do not include any non-work time, even though paid):
Year: Year: Year:
Rate: Rate: Rate:
4. List your firm’s (OSHA/BLS) Total Recordable Incident Rate (TRIR) for the three most recent years. To be satisfactory
without corrective action, that resultant number should be no greater than 5.0. Provide a legible copy of your most
recent OSHA Log (or equivalent) with your submittal.
Year: Year: Year:
Rate: Rate: Rate:
Note: Calculate your TRIR by counting without duplication all recordable injuries and illnesses. For U.S. firms use
the information entered on your OSHA 200 or 300 Form (Line 2A, above), multiply this number by 200,000,
and divide the result by your firm’s total work hours for that calendar year. (i.e. for 2001, take the value
entered in Item 2 A (2001), multiply by 200,000, divide this total by the 2001 employee work hours entered
in Item 3 above).
5. List your firm’s Lost Workday Case Incident Rate (LWCIR) for the three most recent years, as evidenced by your OSHA Log
or equivalent document if non-US.). To be satisfactory without corrective action, that resultant number should be no
greater than 2.0. Provide a legible copy of your most recent OSHA Log (or equivalent) with your submittal.
Year: Year: Year:
Rate: Rate: Rate:
Note: Calculate your LWCIR in the same manner as the TRIR, except use the values reported in 2C, above, rather than 2A.
6. Please list any regulatory agency (e.g., OSHA, SH&S, EPA, OH&S, EC, state/ provincial agencies, etc.) safety or
environmental citations or notices of violation, reportable spill events, sanitation code violations, or other governmental
1
indications of an HSE incident received by your company during the previous three years. Please attach a copy of each
or a summary describing the incident and how it was resolved.
1
HSE incident means an accident or some other unplanned event that causes or had potential to cause an injury, illness, environmental or property damage,
or loss of production.
Rev. 1 – 3 DEC 2008
Page 8 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
Health, Safety and Environmental Information (HSE)
7. Is the information collected from the OSHA logs/OH&S notices, HSE incident reports, and near miss reports
communicated to the following? If yes, how often?
Yes No Monthly Quarterly Annually
Field Superintendent or Department Mgr
Vice President
President or CEO
Other ____________________
8. How are individual HSE incidents and associated costs recorded? How often are they reported?
Yes No Monthly QuarterlyAnnually Incidents totaled
for entire company
Incidents totaled by project
Incidents subtotaled by superintendent
or dept manager
Incidents subtotaled by foreman/supervisor
Costs totaled for entire company
Costs totaled by project
Costs subtotaled by superintendent
Costs subtotaled by foreman/supervisor
9. Do you have a written HSE program? Yes No
If yes, please attach a copy or a summary of your program, including any HSE, safety, or environmental policy or mission
statements you may have.
10. Does your firm have a Sustainability Program, Policy, or Report? Yes No
If yes, please attach a brief summary.
11. Do you have an orientation program for new hires? Yes No
12. Do you have a program for newly hired or promoted foreman and supervisors? Yes No
13. Do you hold workplace HSE meetings for supervisors? Yes No If yes, how often?
Daily Weekly Bi-Weekly Monthly As Needed
14. Do you hold employee “toolbox” HSE meetings? Yes No If yes, how often?
Daily Weekly Bi-Weekly Monthly As Needed
15. Do you conduct pre-task HSE planning meetings with employees? Yes No
If yes, attach a copy of the program.
16. Do you conduct workplace HSE inspections? Yes No
If yes, who conducts this inspection? _____________________ and how often?
Daily Weekly Bi-Weekly Monthly As Needed
Rev. 1 – 3 DEC 2008
Page 9 of 10
New England Construction Co., Inc.
Subcontractor Pre-Qualification Form
Health, Safety and Environmental Information (HSE)
17. Please identify the most senior executive/manager directly responsible for HSE program management and
implementation at your company:
Name:
Title:
Reports to:
This Form was completed by:
Submitted By: Date:
Signature Title
Telephone:
Fax:
Email Address:
Rev. 1 – 3 DEC 2008
Page 10 of 10
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