New Southwest Elementary School, Austin Independent School District

[Insert Project Name]

City, State

Type:

Organization Name:
Physical Address:
Contact Name:
Contact
Phone Number:
Contact
Fax Number:
Contact
Email Address:
Approximate Contract Amount:

ALL INFORMATION MUST BE COMPLETE

Organization (Section 1)

1.1 How many years has your organization been in business as a contractor/supplier?

______

1.2 How many years has your organization been in business under its present business name?

______

1.3 List of all officers of the company and titles:

______

1.4 Type of Organization: (Select one)

Partnership ______

Individually Owned ______

Corporation ______

Experience (Section 2)

2.1 List the categories of work that your organization normally performs with its own forces.

______

2.2 Claims and Suits. (If the answer to any of the questions below is yes, please attach details.)

2.2.1 Has your organization ever failed to complete any work awarded to it?

______

2.2.2 Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers?

______

2.2.3 Has your organization filed any lawsuits or requested arbitration with regard to construction contracts within the last five years?

______

2.3 Within the last five years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract? (If the answer is yes, please attach details.)

______

2.4 On a separate sheet, list major construction projects your organization has in progress, giving the name of the project, owner, architect, contract amount, percent complete and scheduled completion date.

2.4.1 State total worth of work in progress and under contract: ______

2.5 On a separate sheet, list the major projects your organization has completed in the past five years, giving the name of the project, owner, architect, contract amount, date of completion and percentage of the cost of the work performed with your own forces.

2.5.1 State average annual amount of construction work performed during the past five years:

______

2.6 On a separate sheet, list the construction experience and present commitments of the key individuals of your organization.

2.7 Has your organization performed work for any of the SpawGlass companies (Austin, Houston, North Texas, San Antonio and/or South Texas)?

______

2.7.1 If the answer is yes, please list the name(s) of the project(s) you were under contract on, the SpawGlass superintendent and project manager in charge and the final contract amount. (Please list only the five largest projects you completed with SpawGlass.)

______

2.8 Has your organization ever performed work for this owner? ______

2.8.1 If the answer is yes, please list the three most recent projects.

______

References (Section 3)

3.1 Trade References: List at least four general contractors and four suppliers with whom you do business. All information is required.

Contractors:

Company Name
Address
City State Zip
Contact Name
Ph:
Fx:
Email
Company Name
Address
City State Zip
Contact Name
Ph:
Fx:
Email
Company Name
Address
City State Zip
Contact Name
Ph:
Fx:
Email
Company Name
Address
City State Zip
Contact Name
Ph:
Fx:
Email

Suppliers/Vendors:

Company Name Acct #
Address
City State Zip
Contact Name
Ph:
Fx:
Email
Company Name Acct #
Address
City State Zip
Contact Name
Ph:
Fx:
Email
Company Name Acct #
Address
City State Zip
Contact Name
Ph:
Fx:
Email
Company Name Acct #
Address
City State Zip
Contact Name
Ph:
Fx:
Email

3.2 Bank References (contact name, email address, phone number, fax number, address and title):

______

3.3 Surety:

3.3.1 Name of bonding company: (Provide a reference letter from your bonding company and aggregate amounts for which they will issue a performance and payment bond. We are not asking for a bond.) Include a contact name and phone number.

______

3.3.2 Name, address and phone number of agent:

______

Safety (Section 4)

This section is not applicable to suppliers. Subcontractors must answer all questions.

Incident Rate and Experience Modification Rate (EMR)

Definitions:

• An “incident” is the OSHA recordable occurrence of any non-fatal injury or work-related illness.

• The EMR is developed by the National Council on Compensation Insurance (NCCI) and is based on actual worker’s compensation losses over a three-year policy period.

Computations:

• Total Incident Rate = Number of injuries and illnesses X 200,000 / total employee hours worked.

• Your EMR can be obtained from your insurance agent

4.1 Provide your total incident rate for each of the last three years:

Year: ______Rate: ______

4.2 Number of fatalities in the last four years: ______

4.3 Does your organization have an "in-house" safety program? (If the answer is yes, please provide a brief description of the program.)

______

4.4 What is your organization's experience modifier for each of the last three years?

Year______Rate______

4.5 Does your organization lease any temporary personnel? ______

4.6 In the last three years, has your organization received any OSHA citations? (If the answer is yes, please provide the date, location and a brief description of the violation.)

______

Financial (Section 5)

5.1 Financial Statement. Please attach latest audited financial statement, including your organization’s balance sheet, income statement, detailed A/R through the audited statement date and detailed A/R through the current date.

5.1.1 Is the attached financial statement for the identical organization named on page one?

______

5.1.2 If not, explain the relationship and financial responsibility of the organization whose financial statement is provided.

______

5.2 Will the organization whose financial statement is attached act as guarantor of the contract for construction?

______

5.3 Does your organization have sufficient operating capital to operate between draw requests?

______

Insurance Requirements (Section 6)

6.1 Please complete the attached SpawGlass sample Insurance Certificate for qualification purposes. As part of the requirements to perform work for SpawGlass, you will be required to meet our standard insurance requirements. Can you meet these requirements?

______

(Standard Subcontract Agreement) Section 7

7.1 Have you reviewed the SpawGlass standard subcontract agreement, and do you agree to the standard language?

______

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