Subcontractor Forms | San Clemente, CA

NEW ESTIMATING SUBCONTRACTOR FORM

Please note, this is form 1 of 2. After you complete and submit this form, you must also complete the second tab form PREQUALIFICATION STATEMENT (see below).

PLEASE PROVIDE YOUR CURRENT COMPANY INFORMATION BELOW ALONG WITH THE AREAS IN WHICH YOUR COMPANY IS CURRENTLY DOING WORK AND/OR IS INTERESTED IN DOING WORK IN THE FUTURE.

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COMPANY NAME

PHONE

ESTIMATOR

ESTIMATING EMAIL ADDRESS

PHONE NUMBER

FAX NUMBER

CELL NUMBER

CONTRACTOR LICENSE NUMBER

FEDERAL TAX ID#

PHYSICAL ADDRESS

CITY

STATE

ZIP

PLEASE LIST ALL TRADE(S) OF WORK YOUR COMPANY PERFORMS

PREVAILING WAGE WORK

YES

DIR#

UNION AFFILIATION

YES

DISADVANTAGED BUSINESS ENTERPRISE

MBE

WBE

SBE

DVBE

PLEASE LIST YOUR E.M.R.

LEED PROJECT EXPERIENCE

YES

ARIZONA CONTRACTOR LICENSE#

NEVADA CONTRACTOR LICENSE#

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PRE-QUALIFICATION STATEMENT

Please note: This is form 2 of 2. You must also complete and submit the NEW ESTIMATING SUBCONTRACTOR FORM (see tab above).

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PROJECT NAME

SUBCONTRACTOR

DATE

ADDRESS

CITY

STATE

ZIP

YOUR COMPANY’S INTERNAL INSURANCE CONTACT

PHONE

FAX

STATE LICENSE#

FEDERAL TAX ID

GOLDEN STATE ACCOUNT#

TRADE(S)

NAME OF INSURANCE AGENT/BROKER

NAME OF AGENT/BROKER CONTACT PERSON

PHONE

FAX

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Dear Agent/Broker:

Your insured, (the above named subcontractor), has submitted a bid package to our organization for the above referenced project. In order for us to evaluate your client’s insurance program to determine if they meet our insurance requirements, we are requesting that you please complete the following and return it to us via facsimile at (949) 218-4629. Time is of the essence and we would like to thank you in advance for your immediate response. If you have any questions, please contact our Insurance Administrator at (949)498-7500.

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GENERAL LIABILITY

COMPANY AFFORDING COVERAGE

EXP. DATE

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CAN SUBCONTRACTOR’S INSURANCE PROVIDE US WITH:

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COVERAGE NOT LESS THAN:

$2,000,000 General Aggregate

YES

General Aggregate limit applies “per project”

YES

$2,000,000 Products and Completed Operations Aggregate

YES

$1,000,000 Each Occurrence

YES

Occurrence based policy?

YES

An attached Additional Insured Endorsement, ISO form CG2010 11 85, or equivalent, listing all the appropriate entities as additional insured’s? (Two or more will be required to be listed) Please provide samples.

YES

Primary Clause/Wording on Additional Insured Endorsement?

YES

Waiver of Subrogation in favor of all appropriate entities? (Two or more will be required to be listed)

YES

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SUBCONTRACTOR PROJECT

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Excess/Umbrella Liability?

YES

COMPANY AFFORDING COVERAGE

EXP. DATE

SUBCONTRACTOR

PROJECT NAME

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AUTOMOBILE LIABILITY

COMPANY AFFORDING COVERAGE

EXP. DATE

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CAN SUBCONTRACTOR’S INSURANCE PROVIDE US WITH:

Statutory Limits?

YES

Employer's Liability?

YES

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COVERAGE NOT LESS THAN:

$1,000,000 Each Accident

YES

$1,000,000 Disease-Each Employee

YES

$1,000,000 Disease-Policy Limit

YES

Waiver of Subrogation in favor of at least one entity (could possibly be two or more)?

YES

The subcontractor’s only employees are sole-proprietors, partners, or executive officers/shareholders who have elected not to be covered?

YES

The subcontractor has entered into an agreement with an employee leasing company that provides employee’s and worker’s compensation insurance coverage?

YES

IF YES – NAME OF THE LEASING COMPANY:

Will leasing company provide a certificate of insurance and waiver of subrogation?

YES

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PROFESSIONAL LIABILITY (ERRORS & OMMISSIONS)

For subcontractors providing design/build including, without limitation, mechanical; electric; plumbing; and/or fire protection.

COMPANY AFFORDING COVERAGE

EXP. DATE

Can subcontractor’s insurance provide us with coverage not less than $1,000,000 each occurrence?

YES

SUBCONTRACTOR:

PROJECT

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SURETY (BONDING)

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1) SURETY INFORMATION

Can you provide Payment, Performance and Bid Bonds?

YES

SURETY COMPANY PROVIDING THE BOND:

CONTACT NAME:

SURETY BROKER PROVIDING THE BOND:

CONTACT NAME:

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RATING

FEDERAL TREASURY LISTING:

A.M. BEST RATING:

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WHAT ARE YOUR BOND RATES?

% 1ST $100,000 IN CONTRACT SIZE

% NEXT $400,000 IN CONTRACT SIZE

% NEXT $2,000,000 IN CONTRACT SIZE

% NEXT $2,500,000 IN CONTRACT SIZE

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2) PROJECT INFORMATION

LARGEST PROJECT COMPLETED TO DATE

YEAR

PROJECT NAME

PROJECT DESCRIPTION

CONTACT NAME

PHONE

FAX

DATE COMPLETED

Bonded?

YES

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SUBCONTRACTOR OR AGENT/BROKER’S ACKNOWLEDGEMENT:

NAME

DATE

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CORPORATE HEADQUARTERS

181 Avenida La Pata Suite 200 San Clemente, CA 92673

ORANGE COUNTY:

(949) 498-7500

FAX:

(949) 498-7992