ATTACHMENT II. The Application includes the forms listed below. These must be completed and submitted in accordance with the Network requirements:

Transcription

1 Application Submission Punch List - Conversion Network The Application includes the forms listed below. These must be completed and submitted in accordance with the Network requirements: RFQ Application Submittal Form (Form CN-1) Contractor Information Form (including license information) (Form CN-2) Quality-Customer Reference Form (Form CN-3) Lead Distribution Area Form (CN-4) Safety Survey Form (CN-5) * The above information constitutes a complete application. Acceptance -Conversion Network Provide With Acceptance to Network Executed Network Agreement Certificates of Insurance* for: 1) Worker's Compensation & Employer's Liability, 2) Commercial General Liability, 3) Excess Liability Insurance, 4) Professional Liability, 5) Commercial Automobile Liability, 6) Employee Crime Liability * (Insurance carriers must be licensed in CT and the applicable Company and its affiliates must be named as additional insured's.)

2 RFQ Application Submittal Form (CN-1) - Conversion Network Application I of (Applicant's Name) (Company Name) hereby apply to participate in the Conversion Network(s) of the following company or companies: (Please check one category:) SCG CNG Both SCG and CNG The following completed forms are included with this application: * Contractor Information Form (Form CN-2) * Quality-Customer Reference Form (Form CN-3) * Lead Distribution Area Form (Form CN-4) * Safety & Health Form (Form CN-5) I understand that submission of this application does not guarantee participation but rather will be used as part of a review process to determine eligibility. Name of Applicant: Title: Signature of Applicant: (Applicant's Written name) (Applicant's Title) (Applicant's signature) (mm/dd/yy) Form 1 of 5 CN-1 8/ 9/ 13

3 Contractor Information Form (CN-2) - Conversion Network Application Please provide the following information. Company's Legal Name: Office Phone No.: Address - Main Office: Office Fax Number: CT Tax Identification Number Office Address: Principal Contact: Principal's Cell Number: Principal's Title: Principal's Address: Primary CT Heating License Holder CT Heating License Number (Primary Holder) License Type(s) Expiration Date (mm/dd/yy) Heating Equipment Installed (please specify) 24 Hour Answering service? (Yes or No) No. of Full Time Office Staff: Periodic Training of Licensed Technicians (Yes or No) Foreign Languages ( Please specify, if none Enter "None" ) Form 2 of 5 CN- 2 8/ 9 /13

4 Statement of Quality & Customer Reference Form (CN-3) --- Conversion Network Application Company Name: I. Company's Statement of Quality (Brief) : II. Are you a member of the Better Business Bureau (BBB)*? Yes If Yes, Current Grade: * BBB membership is not required for Network participation. Non member companies will not be adversely affected. No III. Customer References: (Please provide contact information of five (5) or more recent customer references, including equipment installed, fuel type and installation dates. References may be contacted by the Companies ) Customer Name Street Address Town State Zip Code Phone Number List Equipment installed Fuel type Install date Note: As part of this Application, references may be contacted to determine customer satisfaction with your company and the equipment installation. Form 3 of 5 CN-3 8/ 9 /13

5 Lead Distribution Area Form (CN-4) - Conversion Network Application I. Company Name: II. Type of installations for which you would like to receive leads. Furnaces Boilers Both III. Is your company available for evening/emergency installations? Yes No IV. Number of installation crews to be used. V. Check (X) the Company Program(s) and municipalities where you want to perform conversions. CNG Program SCG Program ALL CNG Municipalities ALL SCG Municipalities Or Selected Municipalities Or Selected Municipalities Avon Branford Berlin Bridgeport Bloomfield Clinton Canton East Haven East Hartford Easton Farmington Fairfield Glastonbury Guilford Granby Hamden Greenwich Madison Hartford Milford Hebron New Haven Manchester North Branford Mansfield North Haven New Britain Old Saybrook Rocky Hill Trumbull Simsbury Westbrook Unionville West Haven West Hartford Weston Wethersfield Westport Windsor Woodbridge CN-4 8/9/13 Form 4 of 5

6 Safety and Health Form (CN-5) - Conversion Network Application Safety and Health Form (CN-5) - Conversion Network Application Safety and Health Questionnaire Company Name: Address: City, State and Zip Code: Company Contact: Telephone #: Address: Fax #: Completed by: 1) In the table below, provide the three most recent full years of incident information for your company. Year Average Exposure Number of Incident Rate # of Lost Incidence # of EMR # of # of Hours Recordable of Recordable Workday Rate of Lost Lost (Must be Fatalities Employees Cases Cases Cases Workday Workdays Verifiable) Cases (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) GUIDANCE IN FILLING OUT THE TABLE (A) YEAR: List the three most recent full calendar years. If less than a year please specify months. (B) Average # of Employees: List the average # of employees who worked during the year. (C) Exposure Hours: List the total number of hours worked during the year by all company employees. (D) Number of Recordable Cases: List the total number of OSHA Recordable cases that occurred in that year. (E) Incidence Rate Number of Recordable of Recordable Cases: Cases X 200,000 Total Exposure Hours A lost workday case will be defined as any Recordable case that results in death or lost workdays with days away (G) Incidence rate Number of lost of workday Recordable cases: Cases X 200,000 Total Exposure Hours (H) Number of Lost Workdays: List the total number of lost workdays experienced by all employees due to injury or job-related illness during the year. (I) EMR- Experience Modification Rate: We require verification for the EMR. Any of the following methods would be acceptable. * A letter from your insurance agent, insurance carrier, or state fund (on their letterhead), verifying the EMR listed above * A copy of the last three (3) years' experience rating calculations sheets, which your insurance carrier should forward to you annually. (J) Number of Fatalities: List the total number of fatalities that resulted from occupational injuries or illnesses. Deaths that occur in the workplace but are not the result of occupational injuries or illnesses should not be included. 2) Are all documents pertaining to this questionnaire available for auditing? If No: Please explain: 3) Does your company hold documented onsite safety meetings (Tailgate/toolbox/pre-job}? If Yes, describe type of meeting and frequency: Form 5 of 5 Is Documentation available? 6

7 Safety and Health Form (CN-5) - Conversion Network Application 4) Does your company perform regular equipment checks on all equipment? If yes, are records available and maintained? 5) Does your company require the following personal protective equipment on a construction site? Comments: 7) Indicate the circumstances in which your company's employees may be subject to alcohol/drug screening. Pre-Employment Reasonable Cause/Suspicion Periodic Follow Up Random Post Accident Return to Duty Other: (explain) 8) Do you provide a formal, documented safety orientation for each newly hired worker? 9) After completing this survey, do you have any additional comments to offer? Comments: 10. Date Completed: 11. Name of Individual Completing Questionnaire: 12. Signature of Individual Completing Questionnaire: CN-5 8/9/13 Form 5 of 5 7