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Subcontractor Prequalification Form

Company Information:

Address:(Required)
Work Type:(Required)

Contact Information:

Main Contact:(Required)
Estimating Contact (if different):

References:

Max. file size: 50 MB.
Reference for any above prior project (Owner's rep or GC's PM):
Company
First Name
Last Name
Title
Email
Phone
 
Use the + to add more references
Max. file size: 50 MB.

Documentation:

Select those attached:
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.

Safety Program Statistics:

Experience Modification Rating (EMR):
Year to date
Last year
2 years ago
3 years ago
Average number of employees:
Year to date
Last year
2 years ago
3 years ago
Hours worked:
Year to date
Last year
2 years ago
3 years ago
# of recordable cases:
Year to date
Last year
2 years ago
3 years ago
(G) # of deaths:
Year to date
Last year
2 years ago
3 years ago
(H) # of cases with days away from work:
Year to date
Last year
2 years ago
3 years ago
(I) # cases with job transfer or restriction:
Year to date
Last year
2 years ago
3 years ago
(J) # other recordable cases:
Year to date
Last year
2 years ago
3 years ago
(K) # of days away from work:
Year to date
Last year
2 years ago
3 years ago
(L) days on job transfer or restriction:
Year to date
Last year
2 years ago
3 years ago
3-year TRIR:
Total # of cases for all 3 years x 200,000) Total number of employee hours for all 3 years:

Safety Questionnaire:

Does your company have a written safety program?(Required)
Max. file size: 50 MB.
Does your company perform safety training for all employees?(Required)
Max. file size: 50 MB.
Does your company have a new hire orientation process for all new hires?(Required)
Do you hold safety meetings?(Required)

OSHA Inspections:

Have you had an OSHA inspection in the past 5 years?(Required)
If yes, were citations issued?

Safety Program Overview:

Submit Application:

Name(Required)
MM slash DD slash YYYY