Industry Partners Industry Partners PREQUALIFICATION FORM Company Name* Mailing Address* Physical address* Website CONTACT Company President/Main contact Name* Email* Phone* Estimating Contact (if different from above) Name Email Phone Safety Program Contact (if different from Main Contact) Name Email Phone Scope of Work * Subcontractor Supplier Trades* Company Type* Corporation LLC Individual Partnership/joint venture OtherOther Date of incorporation Other names your company operates under? Number of Employees Office Management* Administrative/Office* Pre-Construction/Estimating* Total* Field Field Managers/Foremen* On Staff Tradespeople* 1099 Workers* Total* Does your company subcontract any portion of your work? Yes No If yes, Explain Are you an independent contractor under the Colorado Workers compensation Act? Yes No Where is your company willing and able to work? Vail Valley Roaring Fork Valley Summit County Telluride/Western Colorado Other Other work locations Have you completed projects in the areas selected above? Yes No Please list References Project Name* Contact* Contact Type* OwnerSubcontractorPartnerGCOther Email* Phone* AddRemove FINANCIAL Volume of work under contract at this time $0 - $100,000$100,000 - $250,000$250,000 - $750,000$750,000 - $1.5M$1.5M - $5M$5M+ Total Revenue Last Year $0 - $100,000$100,000 - $250,000$250,000 - $750,000$750,000 - $1.5M$1.5M - $5M$5M+ Total Profit before income tax $0 - $100,000$100,000 - $250,000$250 - $750,000$750,000 - $1.5M$1.5M - $5M$5M+ Total Revenue /Profit 2 years ago Total Revenue/profit 3 years ago Do you have a line of credit? Yes No How much credit do you have available? $0 - $100,000$100,000 - $250,000$250,000 - $750,000$750,000 - $1.5M$1.5M - $5M$5M+ What is your total credit against? $0 - $100,000$100,000 - $250,000$250,000 - $750,000$750,000 - $1.5M$1.5M - $5M$5M+ Please attach a current audited financial statement or balance sheet. Drop a file here or click to uploadChoose File Maximum file size: 10MB Are you bondable? Yes No If yes, Please attach bonding agency letter. Drop a file here or click to uploadChoose File Maximum file size: 104.86MB SAFETY/PERFORMANCE WHAT IS YOUR COMPANY'S EMR RATE? Current: Last year: Two years ago: List any/all judgements, pending claims, and lawsuits if any. Have you ever defaulted or failed to complete a project? Yes No If yes, Explain Insurance Requirements: Insurance Requirements: All trade partners are required to meet and provide proof of RA Nelson insurance requirements. Please check each box acknowledging the insurance coverages required to work with RA Nelson. A communication will follow to coordinate with your insurance to confirm you have the required insurance coverages. If you do not currently meet the flowing requirements, our team is happy to work with you to increase your coverage where needed. General Liability Insurance – Occurrence: General Aggregate - $2,000,000 Products – Completed Operations Aggregate - $2,000,000 Personal & Advertising Injury - $1,000,000 Each Occurrence - $1,000,000 Fire Damage Legal Liability - $50,000 Medical Expense - $5,000 Worker’s Compensation Insurance: Worker’s Compensation Coverage Employer’s Liability Coverage: Limit of Liability, Each Accident - $1,000,000 Disease – Policy Limit - $1,000,000 Disease – Each Employee - $1,000,000 Automobile Liability Insurance: Bodily Injury - $1,000,000 Each Accident Damage Combined including Owned, Hired and Non-Owned Autos – Combined Single Limit Umbrella Liability Insurance: Each Occurrence - $1,000,000 Aggregate, and must be following form - $1,000,000 How did you hear about RA Nelson? Do you know anyone at RA Nelson? Captcha Submit Δ
