Build With AnderCorp Trade Partner Prequalification Complete the form below to be considered for upcoming project opportunities with AnderCorp. Vendor Prequalification Application Step 1 of 5 20% General InformationName of BusinessBusiness Address Street Address Address Line 2 City State ZIP / Postal Code Point of Contact First Last Phone NumberEmail Name of Parent CompanyAddress of Parent Company Street Address Address Line 2 City State ZIP / Postal Code Date of Incorporation Month Day Year Type of Company Corp Partnership S Corp Proprietorship LLC Business CertificationsIs your company certified under any of the following classifications? Small Disadvantaged Business (SBD) HUB Zone Small Business (HUB Zone SB) Native American Women-Owned Small Business (WOSB) Serviced-Disabled Veteran-Owned Small Business Concerns (SDVOSMC) Historically Black College & Universities (HBCU) & Minority Institutions (MI) Veteran-Owned Small Business Concerns (VOSMC) Contractor's License NumberStateExpiration Month Day Year Previous Business NamesHas your company operated under any other names? If so, please list them below. Add Remove Work ClassificationPlease list the type(s) of work you are interested in bidding:Please list the categories of work your firm normally performs with your own employees:Please list the geographical areas in which you work: Work ExperienceHas your firm or any other organization, with which the officers or partners were involved during the past three (3) years, ever failed to complete any work awarded? No Yes Please explain:Are there any judgments, claims, arbitrations, proceedings or suits pending/outstanding against your firm or its officers or principals? No Yes Please explain:Has your firm filed any lawsuits or requested arbitration or mediation with regard to construction contracts within the last three (3) years? No Yes Please explain:Has your firm or any of its principals ever petitioned for bankruptcy, failed in business, defaulted or been terminated on a contract awarded to you? No Yes Please explain:Have any of the owners, officers or major stockholders of your Company ever been indicted or convicted of any felony or other criminal conduct? No Yes Please explain:Has your firm ever been disbarred or otherwise precluded from pursuing public work or ever been found to be non-responsive to a public agency? No Yes Please explain:Has your firm ever had a claim made against it for improper, delayed, defective or non-compliant work or failure to meet warranty obligations? No Yes Please explain:Average Job SizeEnter the average dollar ($) value of projects your company typically performs.Largest Job to DateEnter the dollar ($) value of the largest project your company has completed to date. Financial InformationAttach a copy of your latest audited financial statement.Financial information submitted through this form will be treated confidentially and used solely for AnderCorp’s internal review process.Accepted file types: pdf, doc, docx, Max. file size: 25 MB. Bonding InformationBonding Capacity Per ProjectBonding Capacity AggregateBond RateUpload a copy of your “Good Guy Letter” from your surety company.Note: Letter must come directly from the surety company.Accepted file types: pdf, doc, docx, Max. file size: 25 MB. Insurance InformationWorkers’ Compensation EMR RatesEnter your company’s Workers’ Compensation Interstate/Intrastate Experience Modification Rate for the most recent three (3) years.YearEMR Rate Add RemoveEMR Verification LetterAttach a copy of your insurance carrier or state fund, on their letterhead, verifying the EMR rateAccepted file types: pdf, doc, docx, Max. file size: 25 MB. Insurance CertificateUpload your current insurance certificate, including general liability, workers’ compensation, auto, excess, and professional liability, if applicable.Accepted file types: pdf, doc, docx, Max. file size: 25 MB. SafetyOSHA 300/200 LogsUpload copies of your company’s OSHA 300/200 logs for the last three (3) years.Accepted file types: pdf, doc, docx, Max. file size: 25 MB. Has your company recieved any OSHA violation(s) in the last three (3) years? Yes No Please list the year(s) and number of violations.YearNumber of Violations Add RemoveAttach copy of OSHA violation(s), if neccessaryAccepted file types: pdf, doc, docx, Max. file size: 25 MB. Has your company recieved any willful OSHA violation(s)? Yes No Please give a brief description of the violation(s):Have there been any employee deaths in the past three (3) years? Yes No Please give a brief description of the circumstances:Do you have a qualified person responsible for safety within your Company? Yes No Please provide his/her name and contact information: First Last PhoneEmail Does this person do safety inspections on all of your projects? Yes No How often are safety inspections conducted on your projects?Do you have a written Company Safety Policy, and Program and will you provide copies if requested? Yes No Is your company involved in any of the following types of work? Electrical Steel Contracting Roofing Heavy Excavation No of the above Please attach a copy of your Company Safety Policy and Program.Accepted file types: pdf, doc, docx, Max. file size: 25 MB. Does your Company have a substance abuse policy? Yes No Which of the following are included in your policy? Pre-hire/Initial Employment Random Periodic Cause Post Accident/Incident Do you have a return to work/light duty program? Yes No Please describe:Have you ever-implemented 100% fall protection? Yes No If requested can you provide us with a site-specific program addressing the fall hazards in your work? Yes No Does your company require documented safety meetings?If yes, please indicate which of the following groups receive documented safety meetings and how often meetings are conducted. Yes No Field SupervisorsSelect OneYesNoFrequencyNew HiresSelect OneYesNoFrequencyEmployeesSelect OneYesNoFrequencySubcontractors/VendorsSelect OneYesNoFrequencyDoes your Company provide safety training for all employees? Yes No Please list training provided:Does your Company have a disciplinary program in place for safety violations? Yes No Does your Company review the safety management systems of your sub-subcontractors? Yes No Does your Company conduct accident/incident investigations? Yes No
