Subcontractor Prequalification Form

Company Name + Address

Company Representative Name

Phone

Email Address

Website

General

Has company performed work for any of Pulice Construction projects in the past year? If so, provide Pulice project name and location.

Provide NAICS Code

What services will company be providing?

If any, what portions of the work will your company be subcontracting?

Service State(s) for your Company

Minority & Disadvantage Affiliation? (Provide Certification/Affiliation Information)

Required Submittals

(all applicable submittals MUST be provided and labeled accordingly)

Last three (3) calendar years + current year health, safety, or environmental related citations, violations, or other applicable regulatory agency notices and associated corrective actions.

Last three (3) calendar years + current year injury or incident data/logs that applicable regulatory agency(ies) require Company to maintain (I.E., OSHA300 Logs)

Provide Last three (3) calendar years + current year (EMR) Experience Modification Rate. (Must be from insurance broker or workers' compensation carrier.)

Current Company health, safety, and environmental program.

Provide all training records applicable to scope of work & regulatory requirements.

HSE Program

Do you have a documented pre-employment or new hire safety & health orientation program?

Does your company hold mass meetings for employees + supervision?

If so, how often?

DAILYWEEKLYMONTHLY

Do you conduct jobsite safety inspections?

If so, how often?

DAILYWEEKLYMONTHLY

Is Pre-Task Planning Risk Assessment conducted prior to the start of each shift? (I.E., JSAs, Job Briefings, etc.)

Will you have fulltime supervision on site?

Do you employ a fulltime safety professional dedicated to HSE?

What is the name + title of your company's HSE Professional?

What is the email address of your company's HSE Professional?

What is the phone number of your company's HSE Professional?

HSE Performance History

All fields must be populated with a numerical value. If no data is available, indicate with a 0

Current EMR Insurance Rate

EMR Rate for the following years

Current Employee Count

Employee Count for the following years

Current Total Hours Worked

Total Hours for the following years

Current Work Related Incidents/Illnesses

Current Work Related Incidents/Illnesses for the following years

Current Job Transfers

Current job transfers for the following years

Current Total Work Restrictions

Current work restrictions for the following years

Current Total of lost times

Current total Lost Times for the following years

Current Total of Fatalities

Current Total of Fatalities for the following years

Comments

Upload file

No file chosen