Native Hawaiian Owned
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Department of Veterans Affairs – New York
Department of Veterans Affairs – South MATOC
Naval Facilities Engineering Command – Southeast
USACE – Huntsville District Firm Fixed Price Contract
USACE – Norfolk District MATOC
Veterans Affairs – Wilmington Medical Center
VA – NATIONAL CEMETERY ADMINISTRATION
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U.S. Army Corps of Engineers, Homestead ARB, FL
Department of the Air Force – Hurlburt Field
U.S. Army Corps of Engineers Jacksonville District- Florida National Cemetery, Bushnell
U.S. Coast Guard Civil Engineering Unit Providence
National Institutes of Health
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Subcontractor Qualification Form
General Information
Firm Name
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Street Address
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City
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State
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Zip Code
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Phone
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Fax
Point of Contact
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Email Address
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EIN (Tax ID)
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DNB
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Information From the Past Three Years
2018 Annual Gross Revenue
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2018 Annual Avg. # of Employees
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2019 Annual Gross Revenue
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2019 Annual Avg. # of Employees
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2020 Annual Gross Revenue
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2020 Annual Avg. # of Employees
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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?
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Do you have a Corporate Safety Program?
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Yes
No
Option 3
Have you ever been disbarred from the Federal Government?
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Yes
No
If yes - please explain
What cities/states are you available to work in?
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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?
Yes
No
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
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Project 2
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Project 3
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Bonding Capacity
What is your bonding capacity?
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What is your bond rate?
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References
Please include Company - Contact Name - Address - Telephone and Fax
Reference 1
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Reference 2
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Reference 3
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Banking References
Company
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Contact Name
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Street Address
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City/State/Zip
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Telephone
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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
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Title
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Date
Telephone Number
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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)
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