22-076A-RFQ_Attachment_1-Company_Questionnaire.docx

Applicant Name: ______________________________________________________________ Gorge Powerhouse Crane Replacement DB Project PW #2022-076A September 2026 Request for Qualifications (RFQ)

Company Questionnaire

INSTRUCTIONS: Include this form in Section 4 of your SOQ. Provide information to the extent available. The Owner reserves the right to request additional information and verify all responses included.

Applicant’s Legal Business Name*:

“Doing Business Name” (dba), if applicable:

Name of Authorized Representative and Title:

Telephone Number:

E-mail Address:

Back-Up Email Address:

Business Address:

State of WA Contractor Registration No.:

Employment Security Dept. No:

In which State is your company headquarters:

*In Washington, legal business names are recorded with the Secretary of State. You can search on-line (http://www.sos.wa.gov/corps/corps_search.aspx) under your UBI number.

(1) The bonding company (surety) must be registered with the Washington State Insurance Commissioner, appear on the current Authorized Insurance List in the State of Washington published by the Office of the Insurance Commissioner, having a current rating of at least A-VII in A.M. Best’s Key Rating Guide, and be included in the U.S. Department of the Treasury’s Listing of Approved Sureties (Circular 570). The letter does count not for the page count limitation.

(2) For those submitting as a Joint Venture (JV), responses to this questionnaire shall encompass all partners of the JV. The responses must be consistent with the intent of the content of the question. Issue response to question for each JV partner. It is acceptable to submit pages 1 through 4, for each JV partner. The City may request clarification of questions due to the nature of JV.

Bonding and Insurance

Registration with City of Seattle

[NOTE: Not required for this Project; leave blank.]

Ownership (2)

Financial Resources(2)

Social Equity Compliance(2)

Responsibility(2)

Within the previous five years has your firm been the defendant in court on a matter related to any of the following issues:

· Payment to subcontractors?

· Work performance on a contract?

Yes |_| No|_|

Does your firm have outstanding judgments pending against it?

If yes, please attach a brief explaination.

Yes |_| No|_|

Within the previous five years has your firm been assessed liquidated damages on a contract?

Yes |_| No|_|

Within the previous five years has your firm had a complaint or fines, fees or penalties assessed by any regulatory agency? (i.e. Ecology, WSHA, OSHA, L&I)

Yes |_| No|_|

Is your firm currently under investigation for any violations by a regulatory agency?

Yes |_| No|_|

List your firm’s OSHA Experience Factor (Washington State Worker’s Compensation Insurance) for each of the past 3 years. If rating is higher than 1 for the current year, please provide an explanation describing the circumstances.

Notes:

(1) An Experience Factor is calculated annually by the Washington Department of Labor and Industries. More information can be found here: http://www.lni.wa.gov/ClaimsIns/Insurance/RatesRisk/How/ExpFactor/ExpModFactor/

(2) If Applicant is “self-Insured” please attach OSHA 300 logs for the last 3 years and calculate your experience factor using the following website: http://www.ncrb.org/modcalc/Calculator.aspx?Reset=True. Print and attach the calculation.

Current Year:

Previous Year:

Year before Previous Year:

Compliance(2) Please note that criminal convictions alone, are not a basis for rejecting a proposal or individual from this contract. The City may consider whether a conviction has material nexus to contract risks, and whether adjustments to work or assignments should be pursued accordingly. If background checks are needed for individuals who will be performing work, such as field crews, the City contract reserves the right to require such background checks. See policies at http://www.seattle.gov/business/WithSeattle.htm

Is there any other information the City should be aware of regarding your financial, criminal or legal history, that has bearing on the work that the City is considering you to perform? For example: conviction or civil judgement rendering against the firm for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a federal, state or local government contract or subcontract; violation of federal or state antitrust or similar statutes, relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property, any present indictment for, or otherwise criminally or civilly charged by a government entity.

Yes |_| No|_|

Your company has not paid, nor will pay, federal appropriated funds (including profit or fee received under a covered federal transaction), to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on his or her behalf in connection with this solicitation, the Offeror shall notify the City of Seattle and complete and submit, with its offer, OMB standard form LLL, Disclosure of Lobbying Activities?

Yes |_| No|_|

Your company has not, directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of competitive pricing in the preparation and submission of its Proposal?

Yes |_| No|_|

Involvement by Current and Former City Employees(2)

Campaign Contributions(2)

By submittal of this form, the Applicant hereby certifies:

1) Accuracy of all information: All information provided as part of this proposal process is true and accurate.

2) Mandatory Responsibility Criteria: The Applicant is in compliance with all of the responsible bidder requirements under RCW 39.04.350, including: having a certificate of registration under RCW 18.27 prior to bidding; a UBI number; industrial insurance coverage if required under Title 51 RCW; an employment security number under Title 50; and a state excise tax registration number under Title 82. And affirms they not disqualified from bidding on any public works contract under RCW 39.06 or RCW 39.12.065(3).

3) In the past three years, the Applicant has not been convicted of or had a civil judgment rendering against the firm for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a Federal, state or local government, or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property, and my firm is not presently indicted for, or otherwise criminally or civilly charged by a Government entity with, commission of any of these offenses.

4) Applicant has not paid, nor will pay, Federal appropriated funds (including profit or fee received under a covered Federal transaction), to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on his or her behalf in connection with this solicitation, the Applicant shall notify the City of Seattle and complete and submit, with its offer, OMB standard form LLL, Disclosure of Lobbying Activities.

5) Non-Collusion: The Applicant has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free, competitive bidding in the preparation and submission of this Proposal to the Owner for consideration in the award of a contract on the improvement described in the RFQPA.

6) Validity: Any offer submitted by the Applicant in this process is valid until the date the City awards a Contract or rejects all offers;

7) Applicant shall provide immediate written notice to the City of Seattle if, at any time, the Applicant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

City Non-Disclosure Request If you believe any statements or items you submit to the City as part of this response are exempt from disclosure, you must identify and list them below. You must very clearly and specifically identify each statement or item, and the RCW exemption that applies. If awarded a City contract, the same exemption status will carry forward to the contract records.

The City will not exempt materials from disclosure simply because you mark them with a document header or footer, page stamp, or a generic statement that a document is non-disclosable, exempt, confidential, proprietary, or protected. You may not identify the entire page, unless the entire page is within the exemption scope. Only records properly listed on this Form will be protected and withheld for notice. All other records will be considered fully disclosable upon request.

|_| I do not request any information be withheld.

|_| I request the following specific information be withheld. I understand that all other information will be considered public information. For each statement or item you intend to withhold, you must fill out every box below. You should not require an entire page withheld; only request the specific portion subject to the exemption.

Document Page:

Specify the page number on which the material is located within your submittal package (page number) Statement:

Repeat the text you request to be held as confidential, or attach a redacted version.

RCW Exemption:

Specify the RCW exemption including the subheading

For this request to be valid, you must specify the RCW provision or other State or Federal law that designates the documents as exempt from disclosure. For example, potential RCW exemptions include the following:

1. RCW 42.56.230.3 – Personal information - taxpayer

2. RCW 42.56.230.4 – Personal information – Credit card numbers and related

3. RCW 42.56.240 - Investigative, law enforcement and crime victims

4. RCW 42.56.250 – Employment and licensing – specify the applicable subheading

5. RCW 42.56.260 - Real estate appraisals

6. RCW 42.56.270 (Items 1 through 17) – specify which subheading.

7. RCW 42.56.270 (items 1 through 17) – specify applicable subheading

8. RCW 42.56.420 - Security

Equal Benefits Compliance Declaration Please declare one (1) option from the list below that describes the Applicant’s intent to comply with Seattle Municipal Code Chapter 20.45 should you win the contract.

Equal Benefits applies to any contractor location in the United States where substantive contract work is being performed (work directly related in a substantial way to the contract scope and deliverables).

|_| Option A The Applicant makes, or intends to make by the contract award date, all benefits available on an equal basis to its employees with spouses and its employees with domestic partners, and to the spouses and the domestic partners of employees, in every location within the United States where substantial work on contract will be performed.

|_| Option B The Applicant does not make benefits available to either the spouses or the domestic partners of its employees.

|_| Option C The Applicant has no employees.

|_| Option D Collective Bargaining Delay. Benefits are available on an equal basis to non-union workers, but union workers are subject to a collective bargaining agreement that does not provide equal benefits.

|_| Option E Open Enrollment Delay. The first open enrollment period for implementing Equal Benefits is not available until after contract execution

|_| Option F Cash Equivalent Payment. The Applicant intends to provide a cash equivalent payment to eligible employees in lieu of making benefits available.

|_| No United States Presence The Applicant does not perform substantial work for the contract in any United State location.

|_| Non-Compliant The Applicant does not comply and does not intend to comply, and refuses all options provided above.

Equal Benefits Instructions Seattle Municipal Code Chapter 20.45 (SMC 20.45) requires companies executing a City contract to provide health and benefits that are the same or equivalent to domestic partners of employees as to spouses of employees, and of their dependents and family members.

1. Carefully fill out the Equal Benefits Declaration. It is essential to your standing in the evaluation process, so it is important to understand and complete the declaration properly.

2. The Program Administrator for the solicitation can answer many questions. However, you may call the City Equal Benefits Coordinator, Miguel Beltran at 206-684-4525 (MIguel.Beltran@seattle.gov) or the general office at 206-684-0444. Call before you submit your bid to ensure you’ve filled out the form correctly.

3. "Domestic Partner" is any person who is party to a same-sex marriage that is legally recognized in the place of jurisdiction of the marriage, or as a Domestic Partner with the employer or with a government registry established by state or local law. If the employer does not have a registration system and does not intend to implement one, the City of Seattle has a registration system as an option: http://www.seattle.gov/leg/clerk/dpr.htm The City will review your responses and make a final determination. If the information you supply is conflicting or not clearly supported by the documentation that the City receives, the City may reject your entire submittal (bid or proposal) or may seek clarification to ensure the City properly classifies your compliance.

Companies that select “Non Compliant” will be rejected, unless there is no competitor that is compliant, responsive and responsible. The City may also find an Applicant “Non Compliant” upon inspection of their program. Be prepared with documentation to support your declaration. All contracts awarded by the City may be audited for equal benefits compliance. Non-compliance may result in the rejection of a bid or proposal, or termination of the contract.

FAS Rev 10/2017