Prequalification Document Checklist 7-12-21.pdf

Prequalification Document Checklist Contractors interested in being pre-qualified at LLNL are required to complete and submit this checklist along with supporting documentation identified below to the Prequalification Administrator listed on the Prequalification Instruction cover letter.

Company Legal Name Address Primary Contact Name/Title Phone / E-Mail ( ) Contractor License Information State: License Number:

Corporate Information DUNS #: Number of US Citizens Employed:

NAICS Code (s)

1. Contractor License ☐ Provide a copy of the Contractor’s License.

6. Staffing ☐ Provide a copy of the Contractor's ‘Company Information’ page printed directly from the E-Verify System.

2. EMR Documentation ☐Provide a letter from Workers’ Compensation (WC) carrier certifying the EMRs identified on the Questionnaire or a copy of your Workers’ Compensation Loss Run from your WC carrier.

☐If EMR > 1.0, Provide an explanation of the safety methods being implemented to reduce your EMR rate.

7. Surety Letter ☐Surety must be listed on the Department of Treasury’s Listing of Approved Sureties.

☐Provide a certification from the surety or its agent identifying (a) the number of times it has completed the contractor’s work in the past 5 years, (b) total bonding capacity in US dollars, and (c) available bonding capacity (in US dollars) at time of the response.

3. OSHA Logs/Documentation ☐Provide a copy of OSHA Form 300 and 300A for the last 7 years.

Provide an explanation and describe the corrective actions taken to improve safety in the following cases:

☐Occurrence of any fatalities within the last 3 years ☐Receipt of any OSHA or state OSHA citation within the last five years, if any.

☐If the Days Away or OSHA Recordable Incident Rates for the past 3 years are above the national average found on Table 1 of the Bureau of Labor Statistics site.

8. Insurance Requirements ☐Provide a copy of your certificate of insurance showing the name of your insurance carrier, broker, and the following insurance limits.

General Aggregate $5M Products, Completed Operations Aggregate $5M Personal and Advertising Injury $1M Each Occurrence $5M Business Auto Liability (per occurrence) $1M

4. Subcontractor Prequalification Safety Questionnaire Submit the completed questionnaire and provide the following documentation as required.

9. Experience and References Describe any Federal projects or projects demonstrating Contractor’s abilities completed in the past 3 years.

Include (a) value of work performed by contractor and

(b) contact info for each project identified.

5. Corporate Safety Plan Checklist Complete the provided Corporate Safety Plan Checklist https://www.fiscal.treasury.gov/surety-bonds/list-certified-companies.html https://www.fiscal.treasury.gov/surety-bonds/list-certified-companies.html https://www.bls.gov/iif/oshsum.htm