Primary Engineering & Construction

Primary Engineering & Construction

Subcontractor Prequalification Form 2018

Subcontractor Contact Information

Date: Click here to enter a date.

Company Legal Name: Enter Company Legal Name

Operating As Enter Operating Name

Subsidiaries and Divisions Enter name of subsidiaries and/or divisions

Mailing Address: Enter Mailing Address

City:Enter City Province:Enter Province Postal Code: Enter Postal Code

Physical Address (if different than mailing address): Enter street address if mailing address is a PO Box or Rural

City:Enter City Province:Enter Province Postal Code:Enter Postal Code

Company Phone # Enter Phone Number Fax # Enter Fax Number

Contact Person & Title:Enter Main Contact Name and Title

Email Address:Email Web Site:Website Address

Ownership Type: Choose Business Type

*If Incorporated – Please provide a copy of Certificate of Incorporation and provide locations of registration (eg. Extra Provincial) with registration numbers and locations.

Is your company First Nation, Inuit or Métis-owned*? Yes ☐ No ☐

*Defined as a company that is fully or partially-owned (minimum 51%) by a First Nation, Inuit or Métis person(s) or by a First Nation, Inuit or Métis organization (i.e. band-owned).

Is your company affiliated or partnered with a First Nation, Inuit or Métis community or business? Yes ☐ No ☐

If yes, please describe the nature of the relationship. Click here to enter text

Company Owner(s) – Principals (if more than 2 people, provide a separate sheet)

Name Name of Owner #1 Name Name of Owner #2

Address Address Owner #1 AddressAddress Owner #2

City City Owner #1 ProvProvince PC Postal Code City City Owner #2 ProvClick PC Click

Email email Owner #1 PhPh # Owner #1 Email email Owner #2 PhPh # Owner #2

Business Information

# of Years in Business Enter # of Years in Business # of Employees Enter Total # of Employees

Are PO’s Required? Yes ☐ No ☐

What is your company’s return policy/warranty? Describe Warranty/Return Policy – attach if necessary

MainServices Performed:Describe Main Services Offered

Describe OtherServices Available: Describe Additional Services Offered

Bonding Information

Surety Broker and Carrier Name Name

Contact Name Contact Person PhBonding Contact # Email Bonding email contact

Insurance Information - Please attach Certificate of Insurance (see Appendix A)

Insurance Company Name of Broker and Insurance Carrier

General Liability Insurance Coverage Amount $ Enter Liability Insurance Amount Auto Insurance $ Enter Auto Insurance Coverage Amount

Per Occurrence $ Enter Occurrence Coverage Amount Aggregate $ Enter Aggregate Amount

Limit of Professional Liability per claim $ Enter Coverage Amount Per Policy Period $ Enter Policy Period Limit

Insurance Expiration Date Click here to enter a date.

Material Stock Insurance ProvidedYes☐ No☐ Aggregate Amount $ Enter Aggregate Amount

Coverages EnterCoveragesDeductible $ EnterDeductible

Trade Certification(s)

If applicable, please provide your Company’s Trade Certifications.
Trade Enter Trade TradeEnter Trade

Trade Organizations List Any Trade Organizations Here

Capability of Company

1. Provide 3 Major Supplier References

NAME / City/Town / Phone / Fax or Email
Enter Supplier Name / Enter Supplier Location / Enter Supplier Phone Number / Enter Fax or Email /
Enter Supplier Name / Enter Supplier Location / Enter Supplier Phone Number / Enter Fax or Email /
Enter Supplier Name / Enter Supplier Location / Enter Supplier Phone Number / Enter Fax or Email /

Miscellaneous

Has the company had any legal action taken against it within the last three years? Yes ☐ No☐

Have you ever failed to complete any work that was awarded to you? Yes ☐No ☐

If yes, please explainClick here to enter explanation

Does the Company subcontract out any of its work? Yes ☐No ☐

Explain & identify the Subcontractor used Click to enter Sub Contractor(s) and Nature of Work

Are there any liens, Claims, Judgments, Arbitration or Lawsuits that the Company or its principals have been party to in the last 5 years in excess of $10,000? Yes ☐No ☐

Please describeClick to describe situation/type

Quality Control/ Quality Assurance

Does the company have ISO Certification? Yes☐ No☐Which Standard? Click to add standardName and Number Certification No.: Click to add Cert #Certification Date: Click to add Cert DateCertification Body: Click to add Cert Governing Body

Does the Company have and follow its own Quality Management System Yes ☐ No☐

Comments Click here to enter text.

Is a copy of the Company’s QS/QC Manual available: Yes ☐No ☐

How do you deal with defects and quality issues in the company? Click to describe Process

How do you improve the quality of your products and services? Click to describe

Attach Quality Control Process if needed

How do you communicate the issues with your clients? Click to Describe

Health, Safety and Environment

Does the Company have a dated & signed Health & Safety Policy (current year)? (Please provide) Y☐ N☐

Does the Company have a written Health & Safety Program? (Please provide table of contents) Y☐ N☐

Does the Company have a Certificate of Recognition (COR)? (Please provide copy) Y☐ N☐

Does the Company have a full time Health & Safety Coordinator/Manager? Y☐ N☐

Name/Title of Health, Safety & Environment (HSE) Representative Enter Name and Designation/Title

Does the Company have a Health & Safety Orientation Program for new hires? Y☐ N☐

Does the Company have formal Health & Safety training for site supervisors? Y☐ N☐

Does the company have a Substance Abuse Policy that addresses employee consumption of

alcohol and drugs, both on and prior to entering the worksite? Y☐ N☐

Does your company require “toolbox” safety meetings? Y☐ N☐

If yes, how often?List How Often Are Toolbox Meetings Held?

Does your company have a written Environmental Protection Policy? (if yes, please attach) Y☐ N☐

Has the company received any Health & Safety stop work orders in the past 3 years? Y☐ N☐

If Yes, please explain. Click here to enter text.

Has the Company ever had a fatality? (If yes, please provide general details on a separate page.)Y☐ N☐

Has the Company or any employee of the Company ever been charged under any

Occupational or Construction regulations? Y☐ N☐

(If yes, please provide details on a separate page.)

If the Company employs independent contractors do you request Compensation Board Certificates? Y☐ N☐

Are you registered with a Worker’s Compensation Board? Y☐ N☐

(Please provide WCB Clearance letter)

What is the Company’s overall WCB Rating for the past 3 years? Please attach the company’s summary.

Account # / Industry Code # / Enter Year / Enter Year / Enter Year
Enter WCB Account Number(s) / Industry Rate / Employer Rate / Industry Rate / Employer Rate / Industry Rate / Employer Rate
Enter Code / Enter Rate / Enter Employer Rate / Enter Industry Rate / Enter Employer Rate / Enter Industry Rate / Enter Employer Rate /
Enter Code / Enter Rate / Enter Employer Rate / Enter Industry Rate / Enter Employer Rate / Enter Industry Rate / Enter Employer Rate /

Does the company keep HSE statistics? (If Yes, complete the following chart) Y☐ N☐

COMPANY HEALTH, SAFETY AND ENVIRONMENTAL PERFORMANCE
ITEM / Current Year / 3 Previous Years
Enter Yr / Enter Yr / Enter Yr / Enter Yr
Number of Fatalities (Provide details in a separate attachment) / Enter # / Enter # / Enter # / Enter # /
Number of Lost Time Injuries (LTI) / Enter # / Enter # / Enter # / Enter # /
Lost Time Injury Frequency (LTIF) / Enter # / Enter # / Enter # / Enter # /
Number of Work Days Lost / Enter # / Enter # / Enter # / Enter # /
Number of Medical Treatment Cases (MTC) / Enter # / Enter # / Enter # / Enter # /
Total Reportable Injury Frequency (TRIF) / Enter # / Enter # / Enter # / Enter # /
Number of Restricted Work Days / Enter # / Enter # / Enter # / Enter # /
Number of First Aid Incidents (FA) / Enter # / Enter # / Enter # / Enter # /
Total Exposure Hours / Enter # / Enter # / Enter # / Enter # /
WCB Claims (RTW & LTC) / Enter # / Enter # / Enter # / Enter # /
Releases of liquid pollutants to land or water that are reportable to Regulatory Authorities / Enter # / Enter # / Enter # / Enter # /
Non-compliance to legislation that is reportable to Regulatory authorities / Enter # / Enter # / Enter # / Enter # /

Employees

Number of Field Employees: Skilled Click to enter # Unskilled Click to enter #

Number of Office Employees Click to enter #

Does your company track the number of First Nation, Inuit and Métis employees? Y☐ N☐

*If yes, what is the number of First Nation, Inuit or Métis employees?Click here to enter text.

BC Hydro Requirements

Only required for Powerline Technician Companies that work on the BC Hydro system

PQLC Name / PSSP Categories / Expiry / Confined Space Training (Y/N)

Is your company currently a BC Hydro qualified line contractor that can work on the underground and overhead distribution system? Y☐ N☐

Has your company been required by BC Hydro to stand down on all work on the BC Hydro system at any point in the last 3 years? Y☐ N☐

If, yes, please describe what transpiredClick to enter #

We / I authorize the exchange of information with trade suppliers, owner/ contractors and surveyors.

Applicant’s Name Click here to enter text. Title Click here to enter text.

Signature ______Date Click here to enter a date.

END