Vendor Prequalification Questionnaire

Vendor Prequalification Questionnaire

Company Details

Per your W-9

Legal Name of Company*

Federal EIN#*

Company Operating Names

Attach W9*

Please upload your W9 at the bottom of this form.

Legal Name of Parent (please leave blank if N/A)

Year Company Commenced Business*

Company Type*

Date of Legal Formation*

State of Incorporation*

Main Phone Number*

Phone

Main Fax Number

Phone

Website

Company Business Address

Street Address (No PO Box)*

Suite/Floor Number

City*

County

State*

Company Mailing Address

Mailing Address Same as Above?*

Select

Mailing Address

Suite/Floor Number (2)

City (2)

County (2)

State (2)

Management Contact

Management Contact First Name*

Management Contact Last Name*

Management Contact Title*

Management Contact Email*

Management Contact Phone*

Phone

Management Contact Cell Phone

Phone

Is this individual authorized to Sign Agreements?*

Select

Estimating / Bid Contact

Estimating/Bid Contact First Name*

Estimating/Bid Contact Last Name*

Estimating/Bid Contact Title*

Estimating/Bid Contact Email*

Estimating/Bid Phone*

Phone

Estimating/Bid Contact Cell Phone

Phone

Additional Company Details

Geographical Preference *

List all geographical areas where you currently operate or from which you are interested in receiving solicitations for prospective work.

Interested Scope(s) of Work*

List all scopes of work on which you are interested in working with Flatiron for either a current job or future jobs.

Minority/Diversity Classification*

UBE is an all-inclusive term for Business Enterprises with Minority, Women, Disadvantaged, Veteran, Etc. Certifications.

Select

Other Minority/Diversity Classification

Safety Details

Note: It is the sole discretion of Flatiron to approve or disapprove a subcontractor with an EMR over 1.0. The subcontractor must demonstrate and document that it has or will initiate programs, policies, and attitudes which will result in safety conscious performance in order to be considered.

EMR Reports Attached*

Please upload your EMR Reports for the current year and 2 years prior at the bottom of the form.

Experience Modification Rate (EMR) current year*

Experience Modification Rate (EMR) last year*

If you do not have an EMR for the 1 year prior, please use N/A.

Experience Modification Rate (EMR) 2 years prior*

If you do not have an EMR for 2 years prior, please use N/A.

OSHA Information

Please provide data for the last 3 years and attach your company's OSHA 300 & 300A Forms.

OSHA Forms 300&300A Attached*

Please upload your OSHA 300 & 300A Forms for the current year and 2 years prior at the bottom of this form.

# of Lost/Restricted Workday Cases - Current Year*

# of Fatalities - Current Year*

Restricted Workday Cases - Current Year*

# of Medical Treatment Cases - Current Year*

# of Lost Workday Cases - Current Year*

Employee Hours Worked - Current Year*

OSHA Recordable Incident Rate - Current Year*

OSHA DART Rate - Current Year*

OSHA Restricted Workday Rate - Current Year*

OSHA Lost Workday Incident Rate - Current Year*

# of OSHA violation(s) received in past 3 years*

Any Serious or Willful OSHA Violations?*

Select

Safety Questionnaire

Company Safety Policy/Program Attached*

Please upload your company safety policy/program at the bottom of this form.

Any employee/sub tier deaths in the past 3 years?*

Select

Full-time certified safety professional?*

Do you have a full-time qualified, credentialed safety professional responsible for safety within your company?

Select

Substance Abuse & Drug Policy?*

Does your company have a substance abuse and drug testing policy?

Select

Return to work/light duty program?*

Do you have a return to work/light duty program?

Select

Explain your 100% fall protection policy*

Company provided safety training?*

Does your company provide safety training for all employees?

Select

Company set annual safety training goals?*

Does your company set annual safety training goals for all employees?

Select

Non-Project Personnel Safety Audit Process?*

Do you have home office representatives (not directly involved in the project) who will visit and audit the project for safety?

Select

Company Review of Subcontractor Safety Data?*

Does your company review the safety management systems, competent persons, safety professionals, and incident records of your subcontractors?

Select

Company Accident/Incident Investigations?*

Does your company conduct accident/incident investigations?

Select

Trade Details

Union Status*

Select

List Unions with which you have agreements

Employment Numbers

How many people does your company presently employ?

# of Home Office Employees*

# of Field Supervisors*

# of Trades People*

Experience / General Project Size

What is the largest dollar contract your company has completed? (Do not include Joint Venture Projects.)

Largest Contract Amount (no JV)*

Largest Contract Project Name*

Largest Contract Year Completed*

Largest Contract Scope of Work Performed*

What is the largest dollar volume job you expect to do during this year?

Largest $ volume - current year - Contract Amount*

Largest $ volume - current year - Project Name*

Largest $ volume - current year - Scope of Work*

Financial Information/Annual Volume

Attach Past 3 Years of Financial Statements*

Please upload your company's financial statements for the most recent fiscal year and 2 previous fiscal years at the bottom of this form.

What is your expected volume this year?

Expected Volume - Current Year - Dollar Amount*

Expected Volume - Current Year - # of Projects*

Current Backlog*

Backlog = amount of revenue the Company expects to realize from work to be performed on uncompleted contracts in progress and from contractual agreements on which work has not yet begun.

% of company's work normally subcontracted*

Environmental Social and Governance (ESG)

Formal ESG Program In Place?*

Does your company have a formal ESG Program?

Select

Tracked Environmental Targets?*

Do you have stated environmental targets for which you track and review performance metrics?

Select

Diverse and/or Local Supplier Spend Metrics?*

Does your company track, and report (direct or indirect) spend with diverse and/or local suppliers?

Select

Human Trafficking Statement/Policy In Place?*

Do you have a documented modern slavery and human trafficking statement and/or policy?

Select

Formal Business Ethics Policy In Place?*

Does your company have a formal policy on business ethics?

Select

Supplier References

List three suppliers with whom you do business.

Supplier Reference 1

Supplier Reference 1 Company*

Supplier Reference 1 City*

Supplier Reference 1 State*

Supplier Reference 1 Contact Person's Name*

Supplier Reference 1 Contact Person's Phone*

Phone

Supplier Reference 1 Contact Person's Email*

Supplier Reference 2

Supplier Reference 2 Company*

Supplier Reference 2 City*

Supplier Reference 2 State*

Supplier Reference 2 Contact Person's Name*

Supplier Reference 2 Contact Person's Phone*

Phone

Supplier Reference 2 Contact Person's Email*

Supplier Reference 3

Supplier Reference 3 Company

Supplier Reference 3 City

Supplier Reference 3 State

Supplier Reference 3 Contact Person's Name

Supplier Reference 3 Contact Person's Phone

Phone

Supplier Reference 3 Contact Person's Email

Contractor References

List three contractors with whom you do business.

Contractor Reference 1

Contractor Reference 1 Company*

Contractor Reference 1 City*

Contractor Reference 1 State*

Contractor Reference 1 Contact Person's Name*

Contractor Reference 1 Contact Person's Phone*

Phone

Contractor Reference 1 Contact Person's Email*

Contractor Reference 2

Contractor Reference 2 Name*

Contractor Reference 2 City*

Contractor Reference 2 State*

Contractor Reference 2 Contact Person's Name*

Contractor Reference 2 Contact Person's Phone*

Phone

Contractor Reference 2 Contact Person's Email*

Contractor Reference 3

Contractor Reference 3 Name

Contractor Reference 3 City

Contractor Reference 3 State

Contractor Reference 3 Contact Person's Name

Contractor Reference 3 Contact Person's Phone

Phone

Contractor Reference 3 Contact Person's Email

Banking Information

Information provided herein shall remain confidential

Bank Name*

Bank Country*

Dunn & Bradstreet Number

Dunn & Bradstreet Rating

Does your company have a bank line of credit?*

Select

Bonding Information

Does your company have a bonding program?*

Select

Insurance

Commercial General Liability

Commercial General Liability Insurance Agent*

Commercial General Liability Insurance Carrier*

Per Project Insurance Limits?*

Select

Current General Aggregate Limit*

Current Products-Comp/Op Limit*

Current Aggregate Limit*

Current Each Occurrence Limit*

Current Deductible*

Current Self Insured Retention*

Excess Liability Insurance

Excess Liability Insurance Agent/Broker*

Excess Liability Insurance Carrier*

Umbrella?*

Select

Excess?*

Select

Current Each Occurrence Limit (Excess)*

Current Aggregate (Excess)*

Workers Compensation and Employer's Liability Insurance

Worker's Comp & Employer Liability Insurance Agent*

Worker's Comp/Employer Liability Insurance Carrier*

Employer's Liability, Each Accident*

Employer's Liability, Disease Each Employee*

Employer's Liability, Disease Policy Limit*

Automobile Liability Insurance

Automobile Liability Insurance Agent*

Automobile Liability Insurance Carrier*

Combined Single Limit (Each Accident)*

Professional Liability Insurance

Professional Liability Insurance (if applicable)*

If not applicable, skip to next section.

Select

Professional Liability Insurance Agent

Professional Liability Insurance Carrier

Self Insured Retention

Office Policy Limit

Deductible

Project Specific Limit Available

Prior Acts

Select or enter value

Extended Reporting Period (tail) in years

Pollution Liability Insurance

Pollution Liability Insurance (if applicable)*

If not applicable, skip to next section.

Select

Pollution Liability Insurance Agent

Pollution Liability Insurance Carrier

Limit Per Occurrence

Aggregate

Self Insured Retention (Pollution)

Deductible (Pollution)

Sample COI and Endorsements Attached*

Please upload your Sample COI & Endorsements at the bottom of this form.

Legal Questionnaire

Bankruptcy, Failed Business, Default Contract*

Has your company or any of its principals ever petitioned for bankruptcy, failed in business, defaulted, or been terminated on a contract awarded to you?

Select or enter value

Felony or Criminal Indictments or Convictions?*

Have any of the owners, officers, or major shareholders of your company ever been indicted or convicted of any felony or other criminal conduct?

Select

Federal/Public Work Preclusions/Suspensions/Etc*

Has your company or any owners, officers or major shareholders ever been suspended, debarred or otherwise precluded from pursuing federal/public work or ever been found to be not responsive by any agency?

Select

Claims for Work or Warranty Failures?*

Has your company ever had a claim made against it for improper, delayed defective, or non-compliant work or failure to meet warranty obligations?

Select

Current Arbitration/ Litigations?*

Is your company or any of its owners, officers or major shareholders currently involved in any arbitration or litigation?

Select

Outstanding Judgements or Claims?*

Does your company have any outstanding judgements or claims against it?

Select

Employment or Immigration Violations?*

Has your company or any of its owners, officers or major shareholders been investigated for or charged with alleged labor law violations of the Immigration Control and Reform Act, or state/local laws regarding employment of immigrations, prevailing wage?

Select

Failed payment litigation within last 5 years*

Please list any litigation brought against your company in the past 5 years asserting that you failed to make payments to anyone.

Non-Disclosure Agreement Statement

Flatiron agrees that the Confidential Information of the Disclosing Party shall be made available only to those of its employees, directors, officers, consultants and advisors (collectively, its “Representatives”) who are involved in the evaluation of the Vendor/Subcontractor and who need access to the Confidential Information in performing their responsibilities in respect of such evaluation and registration of the Vendor/Subcontractor. The Receiving Party shall cause its Representatives to observe the confidentiality obligations.

Certification

We hereby certify that we have answered all of the above questions in a truthful, accurate, and complete manner to assure that our answers (including those answers that may have been copied in from an earlier submission) are not in any respect false or misleading either by expressing ourselves in a misleading or ambiguous manner or omitting information and we also certify that all attachments submitted by us in connection with this prequalification are true, accurate, and full copies of the original documents that are in our possession. We recognize that Flatiron will be relying on the truthfulness and accuracy of our responses to this questionnaire and of the contents of the attachments hereto in deciding whether to permit us to bid as well as in any awards of work that may be made to our Company. Additionally, we agree to promptly notify Flatiron in writing of any events or circumstances that make any of the foregoing answers, attachments, or representations untrue, incomplete, or inaccurate in any material respect.

Officer Name*

This Prequalification has been reviewed by the following officer of our company prior to submittal.

Officer Title*

Date*

File Upload*

Please attach all required documents here. See list below. Please use the following file nomenclature:

W9
3 years of EMR Reports (EMR-Year; Ex. EMR-2024)
3 years of OSHA 300 & 330 Forms (OSHA-Year; Ex. OSHA-2024)
Company Safety Policy
3 years of Financial Statements (Financial Statement-Year; Ex. Financial Statement-2024)
Sample COI with Endorsements

Drag and drop files here or

For questions regarding your Prequalification Submittal, please reach out to SRB-Procurement@flatironcorp.com and someone will follow up within 1 business day.

Send me a copy of my responses

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