Plan Room

		General Contractor Subcontractor              Architect Owner Other
Company Name:	*

Title:

Contact Name:	*
Phone:	*	Extension:

Cell:

Fax:
Address 1:	*
Address 2:
City:	*
State:	*	Select... Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Mariana Islands Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Palau Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming   Zip: *   Country: * Select... US CA MX

Email:

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Trades: (Select up to 5)

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Regions:

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Minority Status		DBE EBE MBE SBE SDVOB TGB WBE WBENC WDB WDBE
Labor Status		Union Non Union
Bondable		Select... Yes No
Type of Business		Corporation LLC Partnership Individually Owned Joint Venture
State of Incorporation		AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NM NV NY OH OK OR PA RI SC SD TN UT VA VT WA WI WV WY
Year Business Started
What is your area of operation?
Areas of Work		USA WI IA IL MN GA ID MO Kenosha/Racine OH KY 100 Miles from Madison NM FL SE WI ND SD UT MI NJ DE SC VA PA MD KS NE NC WY VT ME TN AK TX NY CT VI CA DC MA RI NH OK AR IN NE Wisconsin
Will you travel outside of your area of operation?		Yes No
(1)Corporate Officer/Partner/Proprietor (Name - Position - Percent Owned)
(3)Corporate Officer/Partner/Proprietor (Name - Position - Percent Owned)
(2)Corporate Officer/Partner/Proprietor (Name - Position - Percent Owned)
Were there any changes in ownership in the past 2 years?		Yes No
If so, please explain.
Number of Employees: During the past year.
Number of Employees: During the past 5 years.
Annual Sales Volume: Prior Year #1
Annual Sales Volume: Prior Year #2
Annual Sales Volume: Prior Year #3
Annual Sales Volume: Prior Year #4
Annual Sales Volume: Prior Year #5
List the type(s) of work your firm usually performs with its own crew.
Has your firm ever failed to complete any work awarded to it?		Yes No
If so, please explain in detail.
Is your firm or any of its owners or officers currently involved in any litigation, arbitration, or mediation?		Yes No
If so, please explain this in detail.
(1)Major projects currently in progress (Project - Owner - Architect - Contract Amount - Projected Date of Completion)
(2)Major projects currently in progress (Project - Owner - Architect - Contract Amount - Projected Date of Completion)
(3)Major projects currently in progress (Project - Owner - Architect - Contract Amount - Projected Date of Completion)
(4)Major projects currently in progress (Project - Owner - Architect - Contract Amount - Projected Date of Completion)
(5)Major projects currently in progress (Project - Owner - Architect - Contract Amount - Projected Date of Completion)
Do you have a safety director?		Yes No
Do you have written safety guidelines?		Yes No
Do you hold safety meetings on a regular basis?		Yes No
If so, how often and who attends?
Has OSHA issued any citations to your firm in the last 5 years?		Yes No
If so, please describe the incident and state what action was taken by your firm to prevent a repeat citation?
Does your firm conduct pre-employment drug testing and post accident drug and alcohol testing?		Yes No
Workers Compensation Experience Modification Rates: Prior Year #1
Workers Compensation Experience Modification Rates: Prior Year #2
Workers Compensation Experience Modification Rates: Prior Year #3
Workers Compensation Experience Modification Rates: Prior Year #4
Workers Compensation Experience Modification Rates: Prior Year #5
Name, Address, and Phone Number of your bank

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