2025-987_Contractor_Detail_Verification.pdf
PDF 180 KB Posted
- Attached to
- DNR RFB Long Lake PWA Bituminous Repair
- Solicitation number
- 2000017165
- Issued by
- Houston 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 #2025-987, specifically related to the Long Lake PWA Bituminous Repair project located on Highway 34 in Park Rapids, MN. 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 to be utilized (for contracts under $25,000), subcontractor involvement, and Workers' Compensation Insurance status in Minnesota. Contractors must indicate whether they have employees in the state, disclose any subcontractors (including their percentage of contract value and contact information), and affirm their compliance with workers' compensation requirements. The document emphasizes the legal implications of providing false information, with potential penalties for misrepresentation.
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Other files
| File | Type | Posted |
|---|---|---|
| DNR_RFB_Long_Lake_PWA_Bituminous_Repair.pdf | ||
| 2025-987_Specifications.pdf |
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Text version
DNR Regional Services Solicitation # 2025-987
Email: christine.eck@state.mn.us
CONTRACTOR DETAIL VERIFICATION
Section A
Project Name: Long Lake PWA Bituminous Repair
Project Location: Long Lake PWA, Highway 34, Park Rapids, MN
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 .