Fire Protection Subcontractor Prequalification Form

Company Information

Company Name Contact Person Title Phone Number Email Address City State Zip Code

Company Details

Type of Organization Corporation Partnership Sole Proprietorship LLC Year Established Number of Employees License Numbers (state/municipal) Union Affiliation (if any)

Insurance & Bonding

Insurance Provider Type of Coverage & Limits Bonding Company Bonding Capacity

Capabilities & Experience

Scope of Services Offered Type of Fire Protection Systems Installed Geographic Areas Served List of Relevant Projects Completed in Last 3 Years

References

Owner/GC Reference 1 (Name, Company, Phone) Owner/GC Reference 2 (Name, Company, Phone) Supplier Reference (Name, Phone)

Safety

EMR (Experience Modification Rate) for Past 3 Years OSHA Recordable Incidents Past 3 Years Any Fatalities in the Past 3 Years? No Yes

Additional Comments