Name of "Contractor"
Street Address1
Street Address2
City
State
Zip Code
Phone Number1
Phone Number2
FAX Number
Name of Contact Person
Contact's Phone Number
Ext Cell
Contact's Email
Your Company website
Is the address above
Main Office
Regional Office
Branch Office
Is your company
Architect
General Contractor
Specialty Contractor
Is
your company a certified
MBE
(minority bus enterprise)
No
Yes
WBE
(woman-owned bus enterprise)
No
Yes
DBE
(disadvantaged bus enterprise)
No
Yes
DBB (Detroit based
business) / DSB (Detroit Small Business) / DHB (Detroit head-quartered business)
No
Yes
WCE
(Wayne County enterprise)
No
Yes
OCE
(Oakland County enterprise)
No
Yes
You will be required to
submit copies of all current certificates when requested
Please list the
specialty trade(s) that your Company is interested in bidding.
How many persons does
your company presently employ:
Total employees
City of Detroit Residents
Wayne County Residents
Oakland County Residents
% minority employees
% female employees
In the last 3 years has
your company or any of its principals petitioned for bankruptcy,
failed in business, defaulted or been terminated on a contract awarded
to you?
Yes
No
Have any of the owners,
officers or major stockholders of your Company ever been indicted or
convicted of any felony or other criminal conduct?
Yes
No
In the last 3 years has
your Company or any owners, officers or major stockholders ever been
suspended, disbarred or otherwise precluded from pursuing public work
or ever been found to be non- responsive by a public agency?
Yes
No
In the last 3 years has
your Company had a claim made against it for improper, delayed,
defective or non-compliant work or failure to meet warranty
obligations?
Yes
No
If yes, please explain
Is your Company or any
of its owners, officers or major shareholders currently involved in
any arbitration or litigation?
Yes
No
If yes, please explain
Does you Company have
any outstanding judgments or claims against it?
Yes
No
If yes, please explain
In the past three (3)
years has any litigation brought against your Company asserting that
you failed to make payments to anyone?
Yes
No
Is your Company a union
contractor?
No
Yes
CONTRACTOR PREQUALIFICATION
STATEMENT
Please list your
Company's Workers' Compensation Interstate/Intrastate Experience
Modification Rate for the most recent three years.
INSURANCE QUESTIONNAIRE
Does your Company have a
Commercial General Liability Insurance Policy currently in force?
Does your Company
have a Commercial General Liability Insurance Policy currently in
force?
No
Yes
Does your Company
have a Worker's Compensation and Employer's Liability Insurance
Policy currently in force?
No
Yes
Does your Company
have a Professional Liability Insurance Policy currently in force?
No
Yes
I am an authorized
officer of the Company described as the "Contractor" above. I hereby
represent on behalf of our company that all answers provided in this
Contractor Prequalification Statement is true and correct. We have
attempted to answer all questions in a manner to assure that our
answers are not in any respect misleading, either by expressing
ourselves in a misleading or ambiguous manner or omitting information.
We recognize that DMC Vanguard Health Systems will be relying on the
accuracy of the information and our responses in this questionnaire in
deciding whether to permit us to bid and in awarding work to our
Company.
Form Filling Instructions:
Please remember, once you click the button Submit (below) the
information will be submitted as final. If you click on the "Return to
Form" you will go back to a blank form. All submissions are final,
therefore it is recommended you gather ALL your information together
before filling the form.
