Subcontractor Pre-Qualification Application

* denotes required field

Company

Business Information

Do not use CAPS! please type in upper & lower case

*Business (1099) Name: Country:
*Address: State: City:
*Zip *Main Phone: Fax:
Website:  

Please enter all phone numbers as 1112223333


Is the address above where you want your checks to be mailed?  
Tax Information
Federal ID#:  -
Tax Accounts

State: 


Type: 

Contacts
Contact Phone Ext Cell Email

Trades / Services

Scope(s) of Work
*Scope of Work Name:*Hourly Rate:*Over Time Rate:

Project Range & Travel
*Radius Willing to Travel for Project:
*Price Range of Projects: *# or % of Projects Built in this Range:

License / Regulation

Work Force & Union
*Union Status:
*Number of Field Personnal / Work Force:
Insurance
*Perform Maintenance/Service Work?
*Meet the insurance requirements below?

General Liability: (inclusive of Comprehensive Form, Premises/Operations, Underground Explosions and Collapse Hazard, Products/Completed Operations, Contractual, Independent Contractors, Broad Form Property Damage and Personal Injury) in the amounts of $1,000,000 for each occurrence and $1,000,000 Aggregate.

Automobile Liability: (inclusive of Any Auto, Hired Autos and Non-Owned Auto) in the amount of $1,000,000.

Excess Liability: (inclusive of Umbrella Form) in the amount of $1,000,000 for each occurrence and $1,000,000 aggregate.

Workers' Compensation and Employers' Liability: in the amounts of $100,000 for each accident and $500,000 for Disease-Policy Limit and $100,000 for Disease-Each Employee. Workers' Compensation coverage must extend to every employee, including owners/officers of a closely held corporation and/or individuals operating as a sole proprietorship or partnership.


Retail Construction Services, Inc is listed as additional insured on a primary and non-contributory basis to the General Liability (including completed operations coverage), Business Automobile, and Umbrella/Excess Liability policies. Waivers of Subrogation are included in favor of Retail Construction Services, Inc. on the General Liability, Business Auto, Umbrella/Excess Liability, and Workers Compensation policies. Workers Compensation coverage does extend to the state where the project is located.

License
Type State County City Trade Category License Expiration  

Completed Projects

Projects this Year
*Please list the last three projects you have completed within the last year.
Project Name Project Location General Contractor Contact Phone Amount

Diversity Certifications

Business Diversity Qualifications (WMBE, HUB, etc)
*Is your company a diversity qualified company?     What is this?

ALERT

We see that you are attempting to change either your company name or your Federal ID#. In order for us to process this change, please fax a copy of your W9 form to: 651.704.9100 with a cover note explaining the reason for the change. You will be contacted and the change will be made once the information is verified. If you have any questions, please call 651.704.9000 and ask for Accounts Payable.