2026-801_Contractor_Detail_Verification.pdf
PDF 183 KB Posted
- Attached to
- DNR RFB William O'Brien Day Use Sidewalks
- Solicitation number
- 2000018159
- Issued by
- Washington County, Minnesota
About this file
This is a Contractor Detail Verification form issued by the Minnesota Department of Natural Resources (DNR) Regional Services for Solicitation #2026-801. The form is required for the William O'Brien Day Use Sidewalks Project located at the Walter Mondale Day Use Area in William O'Brien State Park, Marine on St. Croix, Minnesota. Contractors must complete and return this form to christine.eck@state.mn.us before notice to proceed or payments can be processed. The form collects information regarding the contractor's organizational details, the number of trades or occupations to be utilized (particularly relevant for contracts under $25,000), and identification of any subcontractors involved in the project, including their company names, contract value percentages, and contact information.
The form requires contractors to declare their employment status in Minnesota and their compliance with Workers' Compensation Insurance requirements under Minnesota Statute 176.041. Contractors must certify whether they have employees in the state and either confirm workers' compensation coverage or claim an applicable exemption. Any changes to workers' compensation status during the contract term must be reported immediately with updated certificates of insurance provided to the DNR. Contractors must acknowledge that falsification of any information on the form constitutes a false statement subject to legal penalties and grounds for contract forfeiture. Updated forms are required whenever any changes occur in the contractor's circumstances or status.
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Other files
| File | Type | Posted |
|---|---|---|
| 2026-801_Qualification_Form.pdf | ||
| DNR_RFB_William_O_Brien_Day_Use_Sidewalks.pdf | ||
| 2026-801_Specifications.pdf |
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Text version
DNR Regional Services Solicitation # 2026-801
Email: christine.eck@state.mn.us
CONTRACTOR DETAIL VERIFICATION
Section A
Project Name: William O’Brien Day Use Sidewalks
Project Location: Walter Mondale Day Use Area, William O’Brien State Park, Marine on St Croix, MN 55047
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 .