Subcontractor Qualification Form

General Information

Firm Name *
Street Address *
City *
State *
Zip Code *
Phone *
Fax
Point of Contact *
Email Address *
EIN (Tax ID) *
DNB *

Information From the Past Three Years

2018 Annual Gross Revenue *
2018 Annual Avg. # of Employees *
2017 Annual Gross Revenue *
2017 Annual Avg. # of Employees *
2016 Annual Gross Revenue *
2016 Annual Avg. # of Employees *

Additional Business Information

Describe your type of work:
Primary NAICS
Secondary NAICS
Other NAICSs
Applicable Licenses
List all applicable licenses you have or will acquire (including descriptions, numbers and expiration dates) to lawfully execute the subcontract work.
What is your current EMR rating? *
Do you have a Corporate Safety Program? *
YesNoOption 3
Have you ever been disbarred from the Federal Government? *
YesNo
If yes - please explain
What cities/states are you available to work in? *

Insurance

Insurance Requirements All subcontractors doing work for Polu Kai Services, LLC are required to have the following insurance coverage:

Comprehensive General Liability including Blanket Contractual Liability: $1,000,000.00 combined Single Limit for bodily injury and property damage
$2,000,000.00 Aggregate per project or location.
Contractor shall be added as additional insured. Policy shall NOT contain fungi or bacterial agent exclusion and shall so state on Certificate of Insurance.

Automotive Liability (Owned, leased and non‐owned vehicles):
$1,000,000.00 Combined Single Limit for bodily injury and property damage.

Workers Compensation and Employers Liability Coverage:
Statutory Workers Compensation coverage
Employers Liability ‐ $1,000,000.00 each accident / $1,000,000.00 each employee / $1,000,000.00 policy limit

Umbrella Liability Coverage
Limit of Liability: $2 million

A)Your underwriters(s) must provide endorsements naming Polu Kai Services, LLC and the Client as additional insured’s on your Comprehensive Automobile and Vehicle Liability, Commercial General Liability and Contractor’s Pollution Liability insurances policies.

B) Your underwriter(s) must provide policy endorsements waiving its rights of subrogation with respect to Polu Kai Services, LLC and the Client in connection with your Workers’ Compensation/Employer’s Liability; Comprehensive Automobile and Vehicle Liability; Commercial General Liability.

C) Your underwriter(s) must provide a per-project-aggregate endorsement to your Commercial General Liability insurance policy.

D) Your underwriter(s) must provide 30 days written notice to Polu Kai Services, LLC should any of the required insurance policies be canceled prior to their expiration date.
Are you able to meet above insurance requirements?
YesNo

Previous Experience

Previous Experience List three projects you have recently completed at similar facilities(or other facilities, if three projects have no not been completed at similar facilities) involving work of a type and complexity similar to that of the subcontract work. Indicate cost and duration, and name, address, and telephone number of the project owner and client.
Project 1 *
Project 2 *
Project 3 *

Bonding Capacity

What is your bonding capacity? *
What is your bond rate? *

References

Please include Company - Contact Name - Address - Telephone and Fax
Reference 1 *
Reference 2 *
Reference 3 *

Banking References

Company *
Contact Name *
Street Address *
City/State/Zip *
Telephone *
Fax

Authorization

The contractor hereby certifies and represents that the information provided herein is current, accurate and complete. The contractor further certifies that they will notify the Polu Kai Services, LLC Administrators of any changes to the information provided.
Authorized Representative Name *
Title *
Date
Telephone Number *

Certifications and Licenses

Please email copies of W-9, Insurance Certificate, and any applicable licenses to: erin@polukaiservices.com

Security Verification

Please enter any two digits with no spaces (Example: 12) *
This box is for spam protection - please leave it blank: