2025-162_Contractor_Detail_Verification.pdf
PDF 490 KB Posted
- Attached to
- DNR RFB Blue Mounds SP Culvert Replacement
- Solicitation number
- 2000016219
- Issued by
- Scott County, Minnesota
About this file
This document is a Contractor Detail Verification form related to a contract opportunity issued by the Minnesota Department of Natural Resources for the Blue Mounds Campground Road Culvert Replacement project located in Rock County near Luverne, Minnesota. The contractor must provide details on the number of trades or occupations utilized for the project, whether subcontractors will be used, and information on the contractor's workers' compensation insurance status. The contractor must sign the form and return it to the Regional Business Office Contract Administrator before a notice to proceed or payments can be processed.
The document does not provide details on pricing terms, set asides, incumbents, funding requirements, or other financial information. It is focused solely on collecting contractor details to verify compliance with state requirements prior to contract award and execution.
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Other files
| File | Type | Posted |
|---|---|---|
| DNR_RFB_Blue_Mounds_SP_Culvert_Replacement.pdf | ||
| 2025-162_Specifications___Terms.pdf.crdownload | CRDOWNLOAD file |
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Text version
DNR Business Office
Solicitation # 2025-162 2115 Birchmont Beach Rd NE
Bemidji, MN 56601
CONTRACTOR DETAIL VERIFICATION
Section A
Project Name: 2025-162 Blue Mounds Campground Road Culvert Replacement
Project Location: Rock County/Near Luverne
Contractor Name: ________________________________________________________________________
Complete this form and return to the Regional Business Office Contract Administrator.
No notice to proceed or payments will be processed without receipt of form.
Section B.
If contract is under $25,000 -- Number of trades or occupations utilized?
(Example: Laborer, Excavator Operator, Truck Driver, Electrician, Cement Mason, Plumber, Roofer)
Section C.
Will subcontractors be utilized on this project?
Yes No If subcontractors will be utilized, please list below. Any change requires an updated form.
Subcontractor Name/Company Address and Phone #
Section D.
I do have employees in the State of Minnesota.
Yes No I do have employees in the State of Minnesota, but I claim exemption from Workers’ Compensation Insurance requirements. You must list the qualifying exemption under MN Statute 176.041 that excludes you from Minnesota Workers’ Compensation requirements. _________________________________________________
I agree if during the course of the contract there is a change in Workers’ Compensation status, I will comply with the Workers’ Compensation Insurance requirements & provide the State of Minnesota, Dept of Natural Resources a certificate of insurance.
I understand that falsification, in any way, of the facts or conditions I have represented herein constitutes a false statement for which penalties under the law apply and which will be just cause for forfeit of contract. (Any change requires an updated form.)
Signature of Contractor Title Date
File details come from the government source that posted it. Updated .