GENERAL INFORMATION: |
| Company Name |
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| Address |
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| City |
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| State |
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| Zip |
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| Phone Number |
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| Fax Number |
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| E-mail |
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| How many years has your company been in business under your present firm name? |
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List Company Officers |
| President |
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| Years of Service:
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| Vice President |
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| Years of Service:
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| Treasurer |
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| Years of Service:
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| Other |
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| Years of Service:
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| Parent Company Name |
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| Address |
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| City |
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| State |
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| Zip |
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| Subsidiary Companies |
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List the three largest projects completed in the last three years.
Please include references, contacts and phone numbers. |
| (Please list customer name, contract amount, contact person, phone number and then hit the RETURN key for each entry) |
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| Dunn & Bradstreet Number |
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| D & B Rating |
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| Can your company secure a bond? |
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| Name of Surety |
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| Surety Phone Number |
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| Available bonding capacity |
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| Bank Guarantees |
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| Bank References |
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| Trade References |
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| List any litigation your company has been involved in within the last 5 years. |
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State annual amount of construction work completed each year for the past five years. |
| Year One: |
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| Year Two: |
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| Year Three: |
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| Year Four: |
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| Year Five: |
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INSURANCE INFORMATION: |
Insurance Carriers / General Liability Carrier Name
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| Address |
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| Type of Coverage |
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| Policy No. |
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| Contact |
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| Phone No. |
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| Workmen's Compensation Carrier: |
| Name |
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| Address |
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| Type of Coverage |
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| Policy No. |
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| Contact |
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| Phone No. |
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| Are you self insured for Workmen's Compensation Insurance? |
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| SAFETY PERFORMANCE: |
| From your OSHA 300 Log for last three years: |
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| A. Experience Modification Rate |
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| B. Total Number of Man-hours |
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| C. Number of Injuries Without Lost Workdays (Line 6) |
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| D. Number of Lost Workday Cases (Line 3) |
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| E. Number of Fatalities (Line 1) |
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| F. Total Number of OSHA 300 Recordables |
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| G. Total Case Incident Rate (TCIR) |
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| H. Lost Workday Case Incident Rate (LWCIR) |
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Total Case Incident Rate should be calculated for each year using the following formula:
(F above) X 200,000
Employee Hours Worked (Given Year) |
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Lost Workday Case Incident Rate should be calculated for each year using the following
formula:
(D above) X 200,000
Employee Hours Worked (Given Year) |
| Please submit a copy of your OSHA 300 form and EMR Verification letter from your Workman’s Compensation carrier for each year listed above. |
| Does your company have a written safety program? |
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| Does your company have a safety training program for foreman or supervisors? |
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| Does your company have a written substance abuse policy? |
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| Does your company have an orientation program for new hires? |
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| Does your company hold safety meetings? |
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| (If yes, how frequently?) |
Daily
Weekly
As Needed |
| Does your company have an individual assigned to company safety responsibilities? |
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| If yes, Name |
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| If yes, Phone |
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| Does your company conduct project safety inspections? |
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| If yes, who conducts these inspections? |
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| If yes, how often? |
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| OSHA INSPECTIONS: |
| Have you had any OSHA Inspections in the past 5 years? |
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| If yes... |
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| List the number of inspections that derived from employee complaints |
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| List the number of random inspections |
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| List the number of post accident inspections |
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| List the number of OSHA citations |
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| List the types of citations and dates |
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| I certify that above is true to best of my knowledge and have verified my answers: |
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| Name |
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| Title |
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| Date |
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To which Harper Industries company are you submitting qualifications?
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Harper Construction
Federal Materials
Frontier Materials Concrete
Frontier Aggregates, Inc.
Metro Ready Mix Concrete
Morsey Constructors
Precision Steel
Vanguard Contractors
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