2025-971_Contractor_Detail_Verification_Form.pdf
PDF 180 KB Posted
- Solicitation number
- 2000017152
- Issued by
- Lac Qui Parle County, Minnesota
About this file
The document is a Contractor Detail Verification Form issued by the Minnesota Department of Natural Resources (DNR) Regional Services for Solicitation #2025-971, specifically for the Sibley SP Interpretive Center Light Upgrade REBID project located in Kandiyohi County near New London. The form is designed to collect critical contractor information before project commencement, with a clear stipulation that no notice to proceed or payments will be processed without the completed form.
The form requires contractors to provide details about their workforce, including the number of trades or occupations utilized (if the contract is under $25,000), potential subcontractor involvement, and workers' compensation insurance status in Minnesota. Contractors must disclose whether they have employees in the state and certify their compliance with workers' compensation requirements. The document emphasizes the importance of accuracy, stating that falsification of any information constitutes a false statement and may result in contract forfeiture, with provisions for updating the form if any contract details change during the project.
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Text version
DNR Regional Services Solicitation # 2025-971
Email: christine.eck@state.mn.us
CONTRACTOR DETAIL VERIFICATION
Section A
Project Name: Sibley SP Interpretive Center Light Upgrade REBID
Project Location: Kandiyohi County/Near New London
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 .