4-TB2624-GDP - Attachment B - McKinstry Prequalification Application.pdf

PAGE 1 OF 4 Rev1.2 – MAR 2021

McKinstry Subcontractor Safety Prequalification

Please complete and provide all requested information.

GENERAL INFORMATION

Company Name:

Trade Name (DBA):

Address Line 1:

Address Line 2:

City, State, and Zip Code:

Vendor Contact:

Business ID #, Tax ID or Federal ID/SS #:

Qualifications/License to provide Service:

(State) Contractors License #:

(State) Business License #:

SAFETY AND HEALTH PERFORMANCE

I have attached a copy of the following:

☐ Letter from my Workers Compensation Insurance Provider demonstrating my firm’s EMR rating for the past 3 years.

☐ Copies of my OSHA 300-A logs for the past 3 years

☐ Copies of any OSHA Citations for the past 3 year

Who is responsible for safety at your company?

Name Title

Does your company have a written safety program? Check one. ☐ YES ☐ NO

INSURANCE & BONDING

I have attached a copy of the following:

☐ Current copy of Liability Insurance Certificate

☐ COI w/ evidence of workers compensation coverage (unless located and performing work in Texas)

☐ Letter from Bonding Company/Surety (statement of bonding capacity)

☐ Current W-9 form (must be the most recent version of W-9)

PAGE 2 OF 4 Rev1.2 – MAR 2021

ORGANIZATION & WORK HISTORY

Who do you normally employ? ☐ Union personnel ☐ Non-union personnel ☐ Leased personnel

ANNUAL DOLLAR VOLUME PAST 3 YEARS:

Year $

Year $

Year $

Largest project past 3 years $

Average project size past 3 years $

DESIRED PROJECT SIZE:

Maximum $

Minimum $

MAJOR JOBS CURRENTLY IN CONSTRUCTION:

Location Customer

Type of Work Client Contact Name

Size $ Client Contact Phone

MAJOR JOBS IN PAST 3 YEARS:

PAGE 3 OF 4 Rev1.2 – MAR 2021

Are there any judgments, claims or suits pending or outstanding against your company?

☐ Yes, please attach details ☐ No

Are you now or have you ever been involved in any bankruptcy or reorganization proceedings?

☐ Yes, please attach details ☐ No

Has your firm ever had a claim against a bond on which your firm stood as principle?

☐ Yes, please attach details ☐ No

Has your firm ever been denied a bond?

☐ Yes, please attach details ☐ No

REFERENCES

Provide a minimum of three references that can provide information on your company’s experience on projects of similar size and scope of work:

Name Title

Company Phone

Email

REPORT COMPLETED BY:

Name Title Date

FOR INTERNAL USE ONLY

Number Date Incorporated Changes Point of Contact

1.0 11-30-2016 Initial Release Jason Engelbrecht

1.1 02-22-2020 Released As Is Mark Brewster

1.2 03-24-2021 Under Revision Britin Lindberg

PAGE 4 OF 4 Rev1.2 – MAR 2021

DIVERSITY, EQUITY, AND INCLUSION

McKinstry is deeply committed to advancing diversity, equity, and inclusion in our company and in the industry overall.

Addressing the equity crisis is a top-line aspiration – one of only three – in our guiding 2025 plan. As part of this effort, we have developed a comprehensive five-year plan focused around advancing racial equity, strengthening inclusive jobsite culture, upskilling our people, building personal ownership, driving equity outcomes in local communities, and demonstrating durability and commitment. McKinstry welcomes partnership and engagement in advancing social equity on our projects and through our partnerships. Please tell us more about your diversity, equity, and inclusion efforts below.

1. Are you a certified diverse business? If yes, please list your type of certification and name of the certifying agency. ☐ Yes ☐ No

Certification Type Certifying Agency

2. Do you have a stated corporate commitment to Diversity, Equity, and Inclusion (DEI)? ☐ Yes ☐ No

3. Do you have a Diversity, Equity, and Inclusion (DEI) strategic initiative or program in place? ☐ Yes ☐ No

4. If you have an initiative or program, what does the program entail?

5. How will your company engage within this project to advance equity and social justice?