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 Alliant Construction  601-933-3066

Subcontractor Pre-Qualification Form

Company Information
Company Profile
Company Organization
Bonding & Insurance
Safety Information
Sales Information
Vendor References
General Contracting
Bank References
Major Projects
Claims History
Credit Authorization
Review
Company Information
Company Profile
Company Organization
Bonding & Insurance
Safety Information
Sales Information
Vendor References
General Contracting
Bank References
Major Projects
Claims History
Credit Authorization
Review
Submit
* Required Field

Company Information

List the corporate officers, partners or proprietors of your firm.

Name
Title
Ownership %
%
National Construction Trade Association Membership

Company Profile

* Type of Company
* Project Size (Check all that apply)
* Types of Projects (Check all that apply)
* Certified Minority Business Enterprise Contractor (MBE)?
* Certified Women Business Enterprise Contractor (WBE)?
Do you have experience with LEED/Green buildings?
Do you have experience with Design/Build?

Company Organization

* Organization Type
* List of states/metro areas in which authorized to do work (please include license number where applicable):

Bonding & Insurance

Please attach insurance certificates per sample provided

Do you currently carry or can you obtain the following insurance coverage:
Workers' Compensation Statutory Maximum at Project Site Location
General Liability $1,000,000/$2,000,000 Aggregate
Employer Liability $1,000,000/per statute
Automobile Liability $1,000,000/CSL
Umbrella Liability $1,000,000/$1,000,000 aggregate

Safety Information

Experience Modification Rate (EMR) for last three years:

Number of OSHA recordable incidents over the last three years:
* Do you have a written safety program?
* Are all employees trained in safety requirements?
* Do you have a company Safety Director or other safety professionals on staff?

Sales Information

Three prior fiscal years; 1 is more recent, 3 is oldest.
Year 1
Year 2
Year 3

Vendor References

Please list two vendor references from who you have bought materials in the last year.

General Contracting

Please list two general contractors with whom you have worked for in the last year.

Bank References

Please list two banks with whom you have worked with in the last two years.

Major Construction Projects

Please complete requested information on company's recent major construction projects either completed or in progress.

Claims History

* Have you failed to complete awarded work or been terminated for cause? Do you have any judgements, claims, arbitrations, suits or liens currently against your organization, or have you had any bankruptcies or reorganizations in the last 10 years?
* Within the past five years, has your company or any of the individuals identified in the Company Information Section of this form been the subject of any criminal indictment or judgment of conviction for any business-related conduct constituting a crime under state or federal law?
* Within the past five years, has your company or any of the individuals identified in the Company Information Section of this form been the subject of any federal or state suspension or disbarment?
* Within the past five years, has your company or any of the individuals identified in the Company Information Section of this form been the subject of any formal proceeding or consent order with a state or federal agency involving a violation of state or federal contracting or environmental laws?

Credit Authorization

The submitter of this pre-qualification form authorizes contacting any of the references given on this form and further authorizes each of those representatives to disclose any and all information the reference may have regarding the submitter. Also, the submitter authorizes the release of credit information including a credit report or other sources of credit information and this authorization shall be without expiration.
Do you agree to the terms above?