Embed Size (px)
Citation preview
LIVE OAK CONTRACTINGVENDOR QUALIFICATION FORM
Company Name Telephone Number( )
Fax Number( )
Street Address City/State/Zip
Years in Business Contract Range (in dollars) SubcontractorSupplier
Principal Contact Cell Phone( )
Email Address
Estimator Cell Phone( )
Email Address
Is your company a certified minoritybusiness enterprise? Yes No
If yes, by Whom: Number of Permanent Employees
Insurance Coverage:I have read and understand LOC Standard insurance requirements. (Please see attached standard insurance requirements)
Yes No
Insurance Company Telephone No.
( )
No Can You Obtain Bonding? Yes
Bonding Company & Current Rate
City/State Telephone No.( )
List Three Reference Projects:Project Name Project Location
Approx Subcontract / PO Amount Start Date Completion Date
General Contractor Contact Contact Phone No. Contact Fax No.
Briefly Describe Work Performed
Project Name Project Location
Approx Subcontract / PO Amount Start Date Completion Date
General Contractor Contact Contact Phone No. Contact Fax No.
Briefly Describe Work Performed
Project Name Project Location
Approx Subcontract / PO Amount Start Date Completion Date
General Contractor Contact Contact Phone No. Contact Fax No.
Briefly Describe Work Performed
Do you have any judgements, claims, arbitrations, suits, or liens currently against your organization: No Yes (If yes, explain on a separate sheet and attach to the form)The undersigned certifies the information provided herein is a clear and accurate representation of this organization’s background.Submitted By (Type Name) :
Title Date
Notes:Please fill in all the blanks (including scope sheet) andanswer all questions. Incomplete forms will not be processed.
Office Use Only__________ COI ______ W-9 ______ Licensing ______ References ______ PM Approval
Listed below are scopes of work that will be associated with your company’s name. Please check all that apply.
GENERAL REQUIREMENTSJobsite OfficePortable ToiletPhotographyDumpstersSurveyingArch/EngineeringTesting
Other
SITEWORKEarthwork/DrainageUtilitiesPavingLandscape/IrrigationPaversTermite TreatmentDeep Foundations
Other
CONCRETEConcrete LaborConcrete MaterialsTilt WallRebarGypcretePrecast
Other
MASONRYMasonry LaborMasonry MaterialCast Stone
Other
METALSStructural SteelOrnamental MetalsLt Gauge Mtl Truss
Other
WOODS / PLASTICSFraming MaterialsFraming LaborTrussesInterior Trim MaterialsInterior Trim LaborExterior Trim MaterialsExterior Trim LaborCabinetsCountertops
Other
THERMAL / MOISTUREMetal RoofingShingle RoofingFlat RoofingGutters/DownspoutsMetal Wall PanelsInsulationSkylightsFireproofingWaterproofingCaulking/Sealants
Other
DOORS / WINDOWSDoors/Frames/HdwreWindows/Patio DoorsStorefront/GlassAccess DoorOverhead Doors
Other
FINISHESStuccoDrywall/Mtl StudsAcoustical CeilingsPainting/WallcoveringTile / StoneCarpet / VCTWood FlooringSpecial Flooring
Other
SPECIALTIES
Toilet AccessoriesLouvers/VentsPrefab FireplacesSignageLockers/ShelvingAwningsMailboxesMailboxes
Other
EQUIPMENTAppliancesTheatre/SoundChurch EquipmentEducational EquipmentMedical EquipmentAutomotive EquipmentIndustrial EquipmentDock Equipment
Other
FURNISHINGSWindow TreatmentsCaseworkSeatingFF&E
Other
SPECIAL CONSTRUCTIONPre-eng Mtl BldgCold StorageSwimming Pools
Other
CONVEYING SYSTEMSElevatorsCranes/HoistsLifts
Other
MECHANICALPlumbingFire ProtectionHVACSeptic Systems
Other
ELECTRICALElectricalSecurity SystemsCommunicationsFire Alarm
Other
Please check only the states in which you are licensed & insured and consistently provide quotes & perform work in. If you only work in a portion ofthe state, provide a brief description of the region or territory of that state that you will work in (i.e. major cities, N.E. corner of state, etc).
Alabama Louisiana OklahomaAlaska Maryland OregonArizona Maine PennsylvaniaArkansas Massachusetts Rhode IslandCalifornia Michigan S. CarolinaColorado Minnesota S. DakotaConnecticut Missouri TennesseeDelaware Montana TexasFlorida Nebraska UtahGeorgia Nevada VermontHawaii New Hampshire VirginiaIdaho New Jersey WashingtonIllinois New Mexico W. VirginiaIndiana New York WashingtonIowa N. Carolina WisconsinKansas N. Dakota WyomingKentucky Ohio
BUSINESS LICENSES_____________________________________ State Business License(s)_____________________________________ Trade License(s)
11/17/16
Name and Address of Subcontractor's Producer
Carrier Must be AM Best Rated A, VII or Higher
Name and Address of Subcontractor
A
C
D
E
1,000,000
50,00010,000
1,000,000
2,000,0002,000,000
B1,000,000
1,000,0001,000,000
500,000500,000
500,000
Installation Floater Per Location $100,000 Minimum
The certificate holder is named as additional insured with respect to General Liability, including Completed Operations, and Automobile Liability on a Primary and Non-Contributory basis as required by written contract with a copy of the endorsement attached to this certificate. Waiver of Subrogation applies with respect to GeneralLiability and Workers Compensation as required by written contract in favor of the Certificate Holder. The General Liability, Autombile Liability, Umbrella Liability andWorkers Compensation policies shall be endorsed to provide for a 30 day Notice of Cancellation in favor of the Certificate Holder.
Live Oak Contracting, LLC118 W. Adams St., Suite 1000Jacksonville, FL 32202
SAMPLE
