2025-533_Contractor_Detail_Verification.pdf
PDF 179 KB Posted
- Attached to
- DNR RFB Great River Bluffs Well Repair
- Solicitation number
- 2000016679
- Issued by
- Wadena County, Minnesota
About this file
This is a Contractor Detail Verification form from the Minnesota Department of Natural Resources (DNR) Regional Services for Solicitation #2025-533 regarding the Great River Bluffs Well Repair project located in Winona County. The form requires contractors to provide essential information before any notice to proceed or payments can be processed, with submissions to be sent to christine.eck@state.mn.us.
The form consists of four sections requiring: basic contractor information (Section A), number of trades/occupations for contracts under $25,000 (Section B), subcontractor details including company names, contract value percentages, and contact information (Section C), and Workers' Compensation Insurance status in Minnesota (Section D). Contractors must declare if they have employees in Minnesota and specify any claimed exemptions under MN Statute 176.041. The form requires contractor signature and emphasizes that any changes to the provided information require an updated form submission.
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Other files
| File | Type | Posted |
|---|---|---|
| DNR_RFB_Great_River_Bluffs_Well_Repair.pdf | ||
| 2025-533_Specifications.pdf |
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Text version
DNR Regional Services Solicitation # 2025-533
Email: christine.eck@state.mn.us
CONTRACTOR DETAIL VERIFICATION
Section A
Project Name: Great River Bluffs Well Repair Project Location: Winona County
Contractor Name: __________________________________________________
Complete this form and return to the email address above.
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 % of value of contract Address & Phone number
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
CONTRACTOR DETAIL VERIFICATION
File details come from the government source that posted it. Updated .