Subcontractor Qualification Form

General Information

Firm Name(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Point of Contact(Required)

First Last

Email(Required)

DNB(Required)

EIN (Tax ID)(Required)

Information from the Past Three Years

Last Year's Annual Gross Revenue(Required)

Last Year's Annual Avg. # of Employees(Required)

2 Years Ago Annual Gross Revenue(Required)

2 Years Ago Annual Avg. # of Employees

3 Years Ago Annual Gross Revenue(Required)

3 Years Ago Annual Avg. # of Employees(Required)

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?(Required)

Do you have a Corporate Safety Program?(Required)

Yes

Have you ever been disbarred from the Federal Government?(Required)

Yes

If yes - please explain

What cities/states are you available to work in?(Required)

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

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

Yes

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(Required)

Project 2(Required)

Project 3(Required)

Bonding Capacity

What is your bonding capacity?(Required)

What is your bond rate?(Required)

References

Please include Company - Contact Name - Address - Telephone and Fax

Reference 1(Required)

Reference 2(Required)

Reference 3(Required)

Banking References

Company(Required)

Contact Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

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(Required)

First Last

Title(Required)

Date

Phone(Required)

Certifications & Licenses

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

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Subcontractor Qualification Form

General Information

Information from the Past Three Years

Additional Business Information

Insurance

Insurance Requirements

Previous Experience

Bonding Capacity

References

Banking References

Authorization

Certifications & Licenses

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