2025-929_Contractor_Detail_Verification.pdf
PDF 180 KB Posted
- Attached to
- DNR RFB Peterson Fish Hatchery Gate
- Solicitation number
- 2000017119
- Issued by
- Goodhue County, Minnesota
About this file
The document is a Contractor Detail Verification form from the Minnesota Department of Natural Resources (DNR) Regional Services for Solicitation #2025-929, specifically for the Peterson Fish Hatchery Gate project. The form is designed to collect critical information from potential contractors, including details about trades or occupations to be utilized, subcontractor involvement, and workers' compensation status.
The form requires contractors to provide specific information, including whether subcontractors will be used, the number of trades or occupations involved (particularly for contracts under $25,000), and confirmation of employee status in Minnesota. Contractors must disclose their workers' compensation insurance status, with options to confirm they have employees in Minnesota or claim an exemption under MN Statute 176.041. The document emphasizes that no notice to proceed or payments will be processed without the completed form, and contractors must agree to update the form if any contract details change.
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Other files
| File | Type | Posted |
|---|---|---|
| 2025-903_EVENT_Specifications_and_Terms.pdf | ||
| 2025-929_Specifications.pdf | ||
| DNR_RFB_Peterson_Fish_Hatchery_Gate.pdf |
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Text version
DNR Regional Services Solicitation # 2025-929
Email: christine.eck@state.mn.us
CONTRACTOR DETAIL VERIFICATION
Section A
Project Name: Peterson Fish Hatchery Gate Project Location: 2025-929
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 .