Subcontractors/Suppliers Qualification Form

General Information

All General Information fields are required except Web Address.

Disadvantaged Business Status

If applicable, you must mail, fax or e-mail a copy of your certification.

	Certifying Agency	Certification No.	Expiration Date
Minority
Woman
Disadvantaged
Veteran
Small Business
Hub Zone

Subcontractor and supplier contact information

Contact Person:	Name	E-mail Address
1) Primary
2) Estimating
If you provide project based labor, you must fill out the Field Performance, Safety and Insurance contact information.
3) Field Performance
4) Safety
5) Insurance
6) For Questions Regarding This Form

Performance

Check all markets in which you are willing to work:

You must check at least one.
CincinnatiColumbusLexingtonNashville
DaytonIndianapolisLouisvilleKnoxville

Check applicable title:

Architect/EngineerManufacturer’s RepGeneral Contractor
SubcontractorDistributor/SupplierBuilding Product Manufacturer
Professional Services

Check all CSI codes that your organization supplies:

You must check at least one.

NOTE: Only subcontractors are required to complete the remainder of this form
(i.e., if you provide field labor, you must complete the following questions).

List the three largest projects completed in the last two years, including references,
contacts and phone numbers.

All project fields are required.
State the annual dollar amount of work performed during the last three years:

List the number of field foremen and craft workers/field technicians presently employed by your company:

How many claims/litigation issues has your company been involved in the last 5 years?

What was the dollar magnitude? $

Do you have a Drug-Free Workplace program in place?Yes No

If yes, is your DFWP certified by the State of Ohio BWC? (Only applicable if you perform work in Ohio.)

Yes No   If yes, provide the Policy No.:

Safety

Workers’ Comp EMR:
Not required for companies established after 2009.

2009:   2008:   2007: (Experience Modification Rate — as provided by your Workers’ Compensation insurance provider.)

This section must be completed using the OSHA 300 form (see formulas).

Not required if company has less than 10 employees or established after 2009.

	2009	2008	2007
Incident Rate
Frequency Rate
Severity Rate
Fatalities
OSHA Citations per Year
Hours Worked per Year

List the states included in the above safety statistical information:

Professional Services (Check All That Apply)

A. ENTER SPECIFIC KEYWORDS DESCRIBING YOUR BUSINESS SPECIALTY (UP TO 500 CHARACTERS)

REFERENCES

b. LIST THREE CURRENT BUSINESS CUSTOMERS (LOCAL OR OTHERWISE) WHICH HAVE BEEN OR ARE NOW YOUR CUSTOMERS.

COMPANY NAME	CONTACT NAME	PHONE NUMBER