Risk_Assessment_Questionnaire.pdf

Contract Risk Assessment Questionnaire

Required Submittals

1. List the full names of any partners, owners, officers or other persons occupying a position of authority or responsibility in your organization.

2. Please provide a financial reference from your bank.

3. Please provide complete copies of your most recent independently audited accounts and annual reports for the last three (3) years. If you are not able to provide this information, please provide details.

4. Please identify any significant changes in the financial position/condition of your business/company/organization since the last independent audit.

5. Does your business/company/organization have a DUNS Number? If so, please provide that number.

6. Please provide a summary of your business/company/organization’s insurance coverage and any material exposures.

7. Please provide the following in bond reference: company, agent, bonding capacity (per project, aggregate), date, amount and type of last bond issued, bond rate.

8. What is your business/company/organization’s bonding capacity? For a single project? For aggregate projects?

9. Attach a list of major projects you/your business/company/organization has in progress showing project name, location, contract amount, percent complete and contact person.

10. What is the estimated total value of your business/company/organizations uncompleted work on all outstanding projects?

Required Responses

11. Have any of the people in item #1 been subject to bankruptcy, insolvency or receivership proceedings? Yes ❒ No❒ If yes, please enclose details.

12. Has your business/company/organization filed for bankruptcy within the last five (5) years? Yes ❒ No❒ If so, please enclose details.

13. Has your business/company/organization ever had a contract for the general type of services/product sought by the County terminated for non-compliance or inadequate performance? Yes ❒ No❒ If yes, please enclose details.

14. Has your business/company/organization ever defaulted on a contract for the general type of services/product being sought by the County? Yes ❒ No❒ If yes, please enclose details.

15. Do you run, or are you willing to run, criminal background checks on all your workers, including employees and subcontractors who may, in the course of their duties, come into contact with vulnerable groups, including the elderly, minors and people with a physical or mental disability? Yes ❒ No❒

16. Has there been, in the last five (5) years, or is there now pending or threatened, any litigation, arbitration, governmental proceeding or regulatory proceeding involving claims in excess of $100,000 with respect to the performance of any services or the provision of any product by your business/company/organization? Yes ❒ No❒ If yes, please enclose details.

17. Has any litigation been settled or otherwise resolved involving your business/company/organization’s performance under a contract for the general type of services/product being sought by the County? Yes ❒ No❒ If yes, please enclose details.

18. Has your business/company/organization fulfilled all of its obligations relating to the payment of social security contributions, payment of taxes, etc. Yes ❒ No❒ If no, please enclose details.

19. Has the Internal Revenue Service or similar state agency conducted an investigation regarding your business/company/organization within the last five (5) years?

Yes ❒ No❒ If yes, please enclose details.

20. In the last five (5) years, has your business/company/organization, been or currently involved in any of the following:

a. Any action, audit or investigation brought by any federal government agency or authority or by any state or local governmental agency? Yes ❒ No❒ If yes, please enclose details.

b. Any criminal proceeding, excluding traffic violations and other minor offenses? Yes ❒ No❒ If yes, please enclose details.

21. In the last five (5) years, has your business/company/organization been debarred or suspended for any reason by any federal, state or local government or has refrained from bidding on a project due to an agreement with such governmental agency?

Yes ❒ No❒ If yes, please attach a full explanation.

22. In the past five (5) years, has your business/company/organization had its surety called upon to complete any contract, whether government or private sector?

Yes ❒ No❒ If yes, please enclose details.

23. In the past five (5) years, has your business/company/organization had a revocation, suspension or disbarment of any business or professional permit and/or license? Yes ❒ No❒ If yes, please enclose details.

24. Within the past five (5) years, has your business/company/organization been subject to a denial or revocation of a government prequalification?

Yes ❒ No❒ If yes, please enclose details.

25. Within the past five (5) years, has your business/company/organization received an unsatisfactory performance assessment(s) from a government entity on a contract? Yes ❒ No❒ If yes, please enclose details.

26. Have you/your business/company/organization ever failed to complete any work awarded? Yes ❒ No❒ If yes, please enclose details.

27. Has your firm or any of its owners, officers or partners ever been convicted of a federal or state crime of fraud, theft, or any other act of dishonesty? Yes ❒ No❒ If “yes,” identify on a separate signed page the person or persons convicted, the court (the county if a state court, the district or location of the federal court), the year and the criminal conduct.

Signature

A. THE UNDERSIGNED HEREBY CERTIFIES THAT THE RESPONSES PROVIDED ARE

CORRECT AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE AND FOR THOSE

RESPONSES GIVEN WHICH ARE BASED ON INFORMATION AND BELIEF, THOSE

RESPONSES ARE TRUE AND CORRECT BASED ON MY PRESENT BELIEF AND

INFORMATION.

B. Dated this ______ day of __________________ of the year _________

Name of organization: _____________________________________________

Signature: _______________________________________________________

Printed Name and title: _____________________________________________