Subcontractor Form – Curtis Construction

489 Page Street | Stoughton, MA 02072 | P: 781-344-2838 | F: 781-344-4365 www.CurtisCon.com

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Home
About Us
- Our Team
- Community Service
What We Do
Projects
News
Contact Us
- Subcontractor Form

Subcontractor Form

Company Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Main Number

Fax

Website / URL

Main Contact *

First

Last

Role/Title

Direct Line

Mobile

Fax

Type of Company *

List of trade(s) of work performed by company *

Federal Tax ID # *

NAICS Code

DUNS #

Average contract Value last three (3) years *

Largest single contract completed in last three (3) years *

Is company directly or indirectly signatory to any labor agreements? *

Yes
No

Is company able to bond projects *

Yes
No

Current Experience Modifier (EMR %) *

Effective Date (mm/yy)

Is the company certified? Check all that apply:

Small Business
Woman Owned Business
Veteran Owned Business
HUB Zone Business
Minority Owned Business
Small Disadvantaged Business
Service Disabled Veteran Owner

List three (3) references:

Firm Reference 1

Company Name

Address Line 1

Address Line 2

City

State

Zip Code

Contact *

First

Last

Phone *

Email *

Firm Reference 2

Company

Address Line 1

Address Line 2

City

State

Zip Code

Contact *

First

Last

Phone *

Email *

Firm Reference 3

Company

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact *

First

Last

Phone *

Email *

Safety Information

Is company part of any OSHA partnership? *

Yes
No

Does company conduct weekly, documented safety audits? *

Yes
No

Does company have a safety management program and safety manual? *

Yes
No

Does company have a full time safety manager/director? *

Yes
No

No Do company trade personnel begin each day with a safety meeting? *

Yes
No

Does company use project specific safety plans? *

Yes
No

Has company or any of its key personnel been cited for any OSHA violation in the past five (5) years (you can research this at http://www.osha.gov/oshstats/)? *

Yes
No

Other Information
In the past five years, has company:

Operated under any other name? *

Yes
No

Had any liens filed against it by any of its subcontractors, suppliers or taxing authority? *

Yes
No

Had any judgments, claims, arbitration proceedings or suits against it or its officers? *

Yes
No

Filed any lawsuits or request arbitration with regard to a construction contract? *

Yes
No

Ever failed to complete a contract, been defaulted, or had a contract terminated? *

Yes
No

Had liquidated damages assessed against it upon completion of a project? *

Yes
No

Had any of its key people been a party to a bankruptcy or reorganization proceeding? *

Yes
No

Had any of its key people been investigated for or found to have committed a violation of any labor laws? *

Yes
No

Had active or inactive exclusions associated with it or any key personnel as determined by the Federal Government Systems for Award Management (S.A.M.)? *

Yes
No

Please provide details explaining any yes answers:

W-9 Form

Click or drag a file to this area to upload.

Insurance Certificate

Click or drag a file to this area to upload.

EMR Letter

Click or drag a file to this area to upload.

Company Information

Click or drag a file to this area to upload.

Additional Information

Click or drag a file to this area to upload.

Additional Comments

Please provide additional information/comments as needed

I hereby certify that the information herein is true and sufficiently complete as not to be misleading:

Signatory *

First

Last

Title

Today's Date

Message

©2019 Curtis Construction Company | 489 Page Street | Stoughton, MA 02072 | P: 781-344-2838 | F: 781-344-4365 | www.CurtisCon.com

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