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Subcontractor/Supplier Prequalification Form

In an effort to better understand your company's qualifications to perform work for Congleton-Hacker Company, we request every Subcontractor complete and submit the required documents.
  • General Company Information

  • Classification

  • Equal Employment Opportunity Status

  • Certificate:Expires: 
    Note: If you do qualify as of the above, you may be required to provide a copy of your certification for each individual category. If you do not qualify or cannot furnish a valid certification as proof of qualification, check "Other".
  • Legal and Financial Information

  • Typical Project Size

  • ProjectLocationSubcontract Amount ($)
  • ProjectLocationSubcontract Amount ($)
  • ProjectLocationSubcontract Amount ($)
  • ProjectLocationSubcontract Amount ($) 
  • Safety - OSHA 300A - Must be Submitted

  • Complete the following for the last three (3) years:

    (Insurance company may be helpful in calculating EMR)
  • 202020192018
  • 202020192018
  • 202020192018
  • 202020192018
  • 202020192018
    (DART - Days Away Restricted or Transferred from work) Please visit www.bls.gov/iif/osheval.htm for rate calculation.
  • 202020192018
  • 202020192018
  • 202020192018
  • Insurance Information:

    You agree to secure the following minimum insurance coverage. We recommend this portion be completed by your insurance agent.
  • Commercial General Liability
    Select Yes or No AND Written on occurrence or Claims made
  • Automobile Liability
    To include any autos, all owned autos, scheduled autos, non-owned autos.
  • Umbrella/Excess Liability
    Select Yes or No AND Written on occurrence or Claims made
  • Workers Compensation
  • If scope requires:
    (Scope includes design work on any professional services)
    (Scope includes earthwork, demolition, abatement, HVAC)
  • You understand that for any and all Congleton-Hacker Company projects, Congleton-Hacker Company, the Owner (and others as specified in Part 1 of the Subcontract Agreement) are added as Additional Insureds under the Subcontractor’s Auto, Commercial General Liability and Umbrella polices. Coverage under such policies shall be primary and non-contributory with the Additional Insureds’ insurance policies being excess over Subcontractor’s coverage. Such primary and non-contributory additional insured coverage shall apply to Completed Operations Coverage as identified in Article 6 of the Subcontract Agreement.
  • References

    With contact information
  • NameContact Info
    (Minimum 1 required)
  • NameContact Info
  • NameContact Info
  • NameContact Info
    (Minimum 2 required)
  • NameContact Info
    (Minimum 2 required)
  • NameContact Info
  • Required Attachments

  • Max. file size: 300 MB.
  • Max. file size: 300 MB.
  • Max. file size: 300 MB.
    (10 employees or more)
  • Max. file size: 300 MB.
  • Max. file size: 300 MB.
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