1901 PRIME SUBCONTRACTOR QC FORM

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Application

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1901 PRIME SUBCONTRACTOR QC FORM

PRIME SUBCONTRACTOR QUALIFICATION FORM

For firms willing to partner with a smaller MBE/DBE subcontractor

1901 PRIME SUBCONTRACTOR QC FORM

Company Name:

Email

Business Address:

Address Line 1

City

State

Zip Code

Phone/Mobile

Website (if applicable):

Year Established:

Legal Structure (Corp, LLC, Sole Prop, etc.):

DUNS Number (if applicable):

Certifying Agency & Certification #: (if applicable)

Primary Contact Name & Title:

State of Incorporation:

Federal EIN:

Primary Trade(s):

MBE

WBE

DBE

Section 3

Other

Other Trades Performed (if any):

Do you self-perform or subcontract your work?:

Have you previously partnered with smaller MBE/DBE firms?

Yes

No

Union Affiliation (if any):

Average # of field employees:

Are you open to mentoring a smaller subcontractor?

Yes

No

Describe your approach to capacity building and technical support for a smaller partner:

Additional Experience and Notes:

List up to three recent projects where you partnered with a small or minority subcontractor:

EMR (Experience Modification Rate) for last 3 years:

OSHA Violations (past 3 years):

Yes

No

If yes explain:

Current Safety Program in place?

Yes

No

Insurance Provider Name:

Workers Comp Carrier:

Bonding Capacity – Single Project / Aggregate:

Certified Payroll Capability:

Yes

No

General Liability Coverage Limit:

Are you bondable?

Yes

No

Surety Company & Contact Info:

General Contractor / Developer References (minimum 2):

DOCUMENT CHECKLIST (attach with submission)

Contractor’s License

MBE/WBE/DBE Certification (if applicable)

Safety Program

Insurance Certificate (ACORD)

W-9

Sample Certified Payroll Report

Attach Documents

Choose File

By signing, I certify the information provided is accurate and complete. I understand this is not a contract or commitment but a request for qualification to partner on the 1901 Development Project.

Signature

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Name (Print):

Title:

Date

Mission
CIC Overview
1901 Project

Workforce Application
Prime Subcontractor QC Form
Subcontractor Qualification Form
Minority Subcontractor Needs Form – Chicagoland (Union & Non-Union)

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