Prequalifications - LS Black Constructors

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email Address for Bid Invites(Required)

Website:

Applicant's Name(Required)

Prefix First Last

Phone(Required)

Cell

Fax

Please Select All That Apply

Subcontractor

DBE

Supplier

Union

SBE

Other

Union Affiliation

Please explain:

Years in business under the current company name:

Names of company officers, principals, partners or owners (please attach resumes):

Federal ID #

State of Incorporation:

Is company capable of engineering design and certification?

Present # of Office Personnel:

Field Personnel:

Is there a project we are currently bidding for which you would like to be considered?

Location of projects for which you would like to submit bids (please select all that apply):

Minnesota

Wisconsin

North Dakota

South Dakota

Other

Please Describe:

Please list the specification section(s) (e.g. 260000 Electrical) you provide:

Type and percentage of work you subcontract to others:

Has your company ever defaulted on or failed to complete a project? If yes, please explain.

Within the last five years has your current firm or any predecessor organization been involved in any litigation, arbitration, or legal dispute with an owner, architect, or general contractor?

Yes

If you answered yes to either question, please explain.

Does your firm have a company-wide safety program?

Yes

What is your current EMR?

Please attach a list of current projects, including: contract amount, expected completion date, architect name, general contractor name, project manager name, and phone.

Drop files here or

Max. file size: 2 GB.

Please attach a list of projects completed in the last five years, including: contract amount, completion date, architect name, general contractor name, project manager name, and phone.

Drop files here or

Max. file size: 2 GB.

Within the last five years has your current firm, any predecessor organization, or any principal in the firm filed for bankruptcy?

Yes

Bank Reference:

Address

Street Address Address Line 2 City State ZIP Code

Bank Contact

First Last

Phone

LS Black has a standard subcontract agreement which is required to be used on all projects. By bidding projects and submitting proposals with LS Black, we hereby agree to execute the standard subcontract agreement and comply with its terms and conditions.

Bonding Agent

Address

Street Address Address Line 2 City State ZIP Code

Bonding Contact

First Last

Phone

Insurance Agent

Address

Street Address Address Line 2 City State ZIP Code

Insurance Contact

First Last

Phone

These are the minimum insurance requirements in our standard subcontract agreement and by bidding projects with Black|Dew we hereby agree to comply with these requirements. These requirements are subject to change and may be different in the specifications provided for each project. If higher limits are required by an Owner, those limits must be complied with.

Workers’ Compensation ------- Statutory Limits

Employers’ Liability

Each Accident - $100,000

Disease – Policy Limit - $500,000

Disease – Each Employee - $100,000

Commercial General Liability – any applicable

Deductible must be shown on the subcontractor’s Insurance certificate.

General Aggregate – Per Project Aggregate - $2,000,000

Products/Completed Operations Aggregate - $2,000,000

Personal Injury and Advertising Aggregate - $1,000,000

Each Occurrence - $1,000,000

Automotive Liability

CSL/Bodily Injury and Property Damage - $1,000,000

Umbrella/Excess Liability

Each Occurrence - $1,000,000

Aggregate - $1,000,000

Please attach a sample certificate of insurance.

Max. file size: 2 GB.

SIGNATURE

First Last

Date

Bid Opportunities

COMPANY INFORMATION

Info

Services

Markets

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