2025_598_Contractor_Detail_Verification.pdf
PDF 174 KB Posted
- Solicitation number
- 2000016686
- Issued by
- Goodhue County, Minnesota
About this file
This is a Contractor Detail Verification form from the Minnesota Department of Natural Resources (DNR) Regional Services for Solicitation #2025-598 regarding the Lanesboro State Fish Hatchery Hillside Tree Removal project located in Fillmore County near Lanesboro. The form requires contractors to provide detailed information before receiving notice to proceed or any payments, including the number of trades/occupations to be utilized if the contract is under $25,000, and whether subcontractors will be employed on the project.
The form requires contractors to declare their employment status in Minnesota and Workers' Compensation Insurance compliance. Contractors must indicate if they have employees in Minnesota and whether they claim any exemptions under MN Statute 176.041 from Workers' Compensation Insurance requirements. The form includes sections for listing subcontractor details including company names, percentage of contract value, and contact information. Any changes to the information provided require an updated form submission, and falsification of information may result in contract forfeiture. The form must be completed, signed, dated, and returned to Sue.Crapser@state.mn.us.
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Other files
| File | Type | Posted |
|---|---|---|
| 2025_598_Event_Specifications.pdf | ||
| DNR-RFB_Lanesboro_State_Fish_Hatchery-Tree_Removal.pdf |
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Text version
DNR Regional Services Solicitation #2025-598
Email: Sue.Crapser@state.mn.us
CONTRACTOR DETAIL VERIFICATION
Section A Project Name: Lanesboro State Fish Hatchery- Hillside Tree Removal Project Location: Fillmore County/Near Lanesboro
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 .