Please complete the following to the best of your ability. We realize that the information requested may not apply to every subcontractor. If you are a supplier, rather than listing previous experiences on past projects, please provide recent data on projects for which you have supplied material.

COMPANY INFORMATION

Company Name:

Specialty:

Fax:

Title:

Pager:

Email:

Cellular Phone:

Telephone:

Address:

Contact Person:

Website address:

SIC Code(s)/NAICS:

Business Status: (Please check all that apply.)

Number of Employees:

Number of Years in Business:

Annual Volume: $

Please indicate if your firm is registered with any of the following Small Business Administration (SBA) programs:

- 8(a) Certification #

Name of Surety:

Is your firm bondable?

Does your firm have a Substance Abuse Program?

Does your firm have a Safety Program?

What is your current EMR (Experience Modification Rating)?

(Multiplier used in workers' compensation premium calculations to recognize accident experience)

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Bonding Limit: $

Subcontractor Qualification Form

- Sample Insurance Certificate

- Sample Insurance Requirements

- PreQual Addendum

SUBCONTRACTOR PREQUALIFICATIONS

State:

City:

Zip:

PROJECT EXPERIENCE

Typical Range of Projects Performed:

Average Project: $

Smallest Project: $

Largest Project:  $

Years of experience on design-build contracts:

Federal:

Non-Federal:

List five completed projects. (List any projects with Marsh first):

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(1) Project Name:

Location:

Point of Contact/Phone Number:

Year work was completed:

$ Value:

(2) Project Name:

Location:

Point of Contact/Phone Number:

Year work was completed:

$ Value:

(3) Project Name:

Location:

Point of Contact/Phone Number:

Year work was completed:

$ Value:

(4) Project Name:

Location:

Point of Contact/Phone Number:

Year work was completed:

$ Value:

(5) Project Name:

Location:

Point of Contact/Phone Number:

Year work was completed:

$ Value:

(1)

(2)

(3)

Please provide at least three suppliers and/or general contractor references:

I am interested in bidding and performing work for Marsh

Title

Date

Name