Contractor_Detail_Verification.pdf
PDF 178 KB Posted
- Attached to
- DNR RFB Beltrami Island Culvert Replacement
- Solicitation number
- 2000016358
- Issued by
- Lake County, Minnesota
About this file
This document is a Contractor Detail Verification form for the Beltrami Island Culvert Replacement project, a state and local contract opportunity issued by the DNR Business Office in Bemidji, Minnesota. The project is located in Lake of the Woods County near Baudette. The form requires the contractor to provide details on the number of trades or occupations utilized, whether subcontractors will be used, and the contractor's workers' compensation insurance status. Changes to this information during the course of the contract require an updated form to be submitted. The contractor must also acknowledge that falsification of any information on the form will result in penalties and contract forfeiture.
The form does not provide specific details on pricing terms, set asides, incumbent contractors, funding sources, or other financial information related to the contract opportunity. The focus is on verifying the contractor's details and compliance with state requirements prior to the issuance of a notice to proceed or payments under the contract.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment_F_Blueprints.pdf | ||
| 2025-351_Specifications.pdf | ||
| DNR_RFB_Beltrami_Island_Culvert_Replacement.pdf |
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Text version
DNR Business Office Solicitation # 2025-351
2115 Birchmont Beach Rd NE Bemidji, MN 56601
CONTRACTOR DETAIL VERIFICATION
Section A
Project Name: Beltrami Island Culvert Replacement Project Location: Lake of the Woods County/Near Baudette
Contractor Name: ________________________________________________________________________
Complete this form and return to the Regional Business Office Contract Administrator.
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 Address and Phone #
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
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