SUBCONTRACTOR QUALIFICATION FORM Basecom Inc., a general contractor, specializes in commercial construction and design build projects. We are highly qualified in construction, construction management, integrated design-building, valued engineering and electrical. Based in Fort Worth, we serve the United States construction market. To be placed on our Subcontractor List, please complete this form and either fax it to: (817) 483-2609 or email: moaxaca@basecominc.com. Any supplemental information you would like to provide is welcome. GENERAL INFORMATION Company Legal Name: DBA: Mailing Address: City, State and Zip: Billing Address: City, State and Zip: Telephone: Fax: Company Principle: Primary Contact / Title: Email Address: Website: Organization: Corporation Partnership Individual Joint Venture Incorporation State: Incorporation Date: Length of time in business: Under Current Name: Under Other Name: Federal Identification Number: Subcontractor Qualification Form 150 - C - 1 -
License Information: License Name License Number State Issued by Type of Business: Architect Subcontractor Inspector Agency Consultant Other Vendor List any subsidiary companies: Percentage of commercial work performed Percentage of residential work performed Experience in the following: (check all that apply) Educational/Schools Religious/Churches Office/Retail Medical/Healthcare Historical Restoration Industrial/Heavy/Highway Single Family Multi Family Neighborhood Development Other What divisions of work do you perform? (Select all that apply) 01 General Requirements 02 Site Construction 03 Concrete 04 Masonry 05 Metals 06 Wood and Plastics 07 Thermal & Moisture Protection 08 Doors and Windows 09 Finishes 10 Specialties 11 Equipment 12 Furnishings 13 Special Construction 14 Conveying Systems 15 Mechanical 16 Electrical 17 Voice and Data Subcontractor Qualification Form 150 - C - 2 -
What specific CSI Specification Sections do you perform? Geographic Areas of Operation: Does your company utilize an isqft account? Is your firm a minority certified business? Yes No Type of certification: MBE WBE DBE SBE HUB NCTRCA Veteran SBA Ethnicity of Owner: Gender of Owner: Male Female Classification certified by: States certified by: CONTACTS *Please attach a copy of all certifications Estimating: Phone: Email: Safety: Phone: Email: Emergency: Phone: Email: Account Payable/Receivable: Name: Phone: Email: Subcontractor Qualification Form 150 - C - 3 -
LEGAL INFORMATION Has your company failed to complete any contracts/work awarded to you? Yes No If yes, please explain on a separate page Has your company been involved in bankruptcy or reorganization? Yes No If yes, please explain on a separate page Are any of your officers, stockholders or key members or any related companies involved in any litigation, disputes, or any judgments pending or rendered? Yes No If yes, please explain on a separate page Total Volume of sales performed for each of the previous five years: Year 2015 2014 2013 2012 2011 Amount BONDING AND INSURANCE Insurance requirements: The Subcontractor shall maintain insurance of the following types: Insurance: Coverage Type Workmen s Compensation General Liability Excess / Umbrella Liability Automobile *Submit a copy of your standard insurance certificate showing coverage and limits. Attached Can your firm meet the requirements: Yes No If no, please explain: Subcontractor Qualification Form 150 - C - 4 -
Insurance Company: Insurance Contact: Telephone: Is your company bondable? Yes Bonding Company: Bonding Capacity: Total: Value of work presently bonded? Contact Name: Fax: No Per Job? Surety Company: Subcontractor s Equipment Policy Any such insurance policy covering Subcontractor s equipment against loss by physical damage shall include an endorsement waiving the insurer s right of subrogation against the Indemnities. Such insurance shall be Subcontractor s sole and complete means of recovery for any such loss. Should Subcontractor choose to self insure this risk, it is expressly agreed that the Subcontractor hereby waives any claim for damage or loss to said equipment in favor of the Indemnities. Evidence of Insurance Evidence of the insurance coverage required to be maintained by the Subcontractor under this agreement, represented by Certificates of Insurance issued by the insurance carrier, must be furnished to the Owner and/or Contractor prior to the Subcontractor starting the Work. Certificates of Insurance shall state that the Owner and/or Contractor will be notified in writing thirty (30) days prior to cancellation, material change, or non-renewal of insurance. Subcontractor will provide Owner and/or Contractor a certified copy of any and all applicable insurance policies upon the request of either Owner and/or Contractor. Timely renewal certificates will be provided to Owner and/or Contractor as the coverage renews. REFERENCES Please list five trade references: Company Name Contact Phone Fax Subcontractor Qualification Form 150 - C - 5 -
Please list three general contractors/construction managers for whom your company has worked with in the past two years: Company Name Contact Address Fax SAFETY HISTORY How many medical treatments did your company have last year: _ How many fatalities did your company have last year: _ Average number of fatalities over the last three years: _ Experience Modification Rate for the past three years: Year 2015 2014 2013 Rate Do you comply with the drug free work act? Yes No Do you have a written safety policy/program? Yes No Have you been cited by OSHA for an OSHA defined serious violation in the past three years? Yes No If yes, please explain on a separate piece of paper. Feel free to attach any other information which you feel is applicable for our review. PROJECT INFORMATION Maximum single contract value awarded to your company: Average contract amount: List any work your company usually self performs: List any work your company usually subcontracts out: Subcontractor Qualification Form 150 - C - 6 -
Attach a list of a maximum of five major/significant construction projects completed in the last five years. Include project name, location, contract amount, owner name, architect name, general contractor name, contact and phone number bid/negotiated and bonded/non-bonded. Attach a list of a maximum of three major/significant construction projects currently in progress or under construction. Include project name, location, contract amount, owner name, architect name, general contractor name, contact and phone number, bid/negotiated and bonded/non-bonded. CONTRACT HISTORY Has your firm, under its current or previous legal name or DBA, worked for Basecom Inc., on any projects in the past two years? Yes No Information submitted by: Name: Title: Company: Phone: Date: Please return completed form to: Mark Oaxaca Basecom, Inc. 5209 Vest Farley Fort Worth, Texas 76119 moaxaca@basecominc.com Signature: Subcontractor Qualification Form 150 - C - 7 -