PipelineSuite Form

Instructions:

Please complete the form below. All fields marked with an asterisk (*) are required to submit the form. If you are unable to compete the form in one sitting, please select the ‘Save Progress’ button to finish at a later time. There is also a ‘copy link’ option that will allow you to send the form to other individuals within your organization so they may complete the form, either in part or in whole. The 'Copy Link' button will appear once you begin completing the form.

Contact Information for Person Completing Pre-Qualification Form

Contact First Name *

Contact Last Name *

Email *

Phone *

Company Information

Company Name *

Address *

City *

State *

Zip *

Phone *

Fax

Website

Years in business under present name *

What markets does your firm work in? *

Market: Advanced Technologies

Market: Commercial

Market: Education

Market: Food & Beverage

Market: Healthcare

Market: Industrial

DUNS Number

Dun & Bradstreet rating

President / CEO Name *

Title *

Cell *

Email *

Safety Director / Manager Name *

Title *

Cell *

Email *

Name of Person in your firm for inquiries *

Title *

Cell *

Email *

Bid Contact Name *

Title *

Cell *

Email *

Second Bid Contact Name

Title

Cell

Third Bid Contact Name

Title

Cell

Bidding Information

Certifications If a MBE, WBE, or DBE or Union Member please submit certificate(s) or other supporting documentation. * File extension must be PDF, Word or Excel

Trades Performed *

Other Trades Performed If your company performs services not listed in the previous question, please list them here

Total Office Staff *

Total Field Staff *

Percentage of self-performed work *

Work in place last year ($) *

Average annual sales last 3 years ($) *

Is your firm in compliance with EEO? *

Yes

Has your firm ever failed to complete a contract? *

Yes

Has your firm, owner, or any officer of the firm ever been involved in bankruptcy reorganization? *

Yes

Has your firm, owner, or any officer of the firm had pending judgments, claims, or suits against it/them? *

Yes

If "yes" to any of the three questions above, please describe briefly.

Finance & Insurance Information

Firm's Financial Institution Name *

Address *

Contact Name

Phone *

Financial Support Please submit your most recent audited financial statements. ALTERNATIVE WAYS TO SUBMIT FINANCIAL STATEMENTS: If you have reservations about submitting financials, we provide other options which can be set up directly with Heather Haydo, Chief Financial Officer with CSM Group at heather.haydo@csmgroup.com. **A Non-Disclosure Agreement can be signed by CSM. ** In lieu of third-party financials, you may submit a letter from your financial institution indicating whether you are in good standing with your accounts and, if you have a current line of credit, include what your line of credit amount is and how much is currently borrowed on that line. This information will be used in conjunction with a bonding letter, as required in the 'Finance & Insurance Information' section of this form. * File extension must be PDF, Word or Excel

Insurance Agency *

Address *

Certificate of Insurance Please submit a sample certificate of insurance with applicable endorsements. Does not need to list The CSM Group as a certificate holder at this stage, but must be current (not expired). All contractors mush have valid insurance to be awarded projects. * File extension must be PDF, Word or Excel

Current General Liability Insurance Expiration Date *

Bonding Agency *

Total aggregate bonding capacity ($) *

Bonding Letter Please submit a Bonding Letter: A letter from your surety provider stating that you are in good standing with the surety and what your single project capacity, aggregate bonding capacity, and amount available. If not bonded, please upload a letter indicating such. * File extension must be PDF, Word or Excel

Value of work currently bonded ($) *

What is your firm's credit rating?

Recently Completed Projects

Project Name *

Project Location/Address *

Architect *

Contract Amount ($) *

Completion Date *

Client Contact Name *

Client Email *

Phone *

Please list the state(s) your firm is qualified to do business in *

Is your firm registered to collect sales and/or use tax in the state(s) where your firm is qualified to do business? *

Yes

Health & Safety Information

# of Lost Workday Cases 2020 *

# of Lost Workday Cases 2021 *

# of Lost Workday Cases 2022 *

# of Cases with Medical Attention Only 2020 *

# of Cases with Medical Attention Only 2021 *

# of Cases with Medical Attention Only 2022 *

Number of Restricted Workday Cases (2020) *

Number of Restricted Workday Cases 2021 *

Number of Restricted Workday Cases 2022 *

Number of Fatalities 2020 *

Number of Fatalities 2021 *

Number of Fatalities 2022 *

Total Recordable Incident Rate (TRIR) 2020 *

Total Recordable Incident Rate (TRIR) 2021 *

Total Number of Recordable Injuries (TRIR) 2022 *

If any year had a TRIR rate above 2.0, please provide a detail Please explain the incident(s) that occurred and any mitigation process put in place to prevent these occurrences from happening again.

EMR 2020 *

EMR 2021 *

EMR 2022 *

EMR Letter Please submit a letter from your insurance agent confirming your EMR for the last three years. If you are exempt from submitting an EMR letter, please upload a letter indicating such. * File extension must be PDF, Word or Excel

Provide any General Liability Losses 2020 *

Provide any General Liability Losses 2021 *

Provide any General Liability Losses 2022 *

Total Number of Employee Hours Worked 2020 *

Total Number of Employee Hours Worked 2021 *

Total Number of Employee Hours Worked 2022 *

Total Number of Illness and/or Injury Hours 2020 *

Total Number of Illness and/or Injury Hours 2021 *

Total Number of Illness and/or Injury Hours 2022 *

Please indicate the frequency of job safety inspections *

Monthly

Weekly

Daily

Who is responsible for performing job site safety inspections?

Safety Inspector's Name *

Safety Inspector's Phone *

If inspections performed by third party, please provide name of company

How many OSHA violations has your firm received in the last 3 years? *

What was/were the severity of the violation(s)?

Explain each violation in detail

Past Three Years OSHA Logs Please submit the past three years of OSHA Form 300 Logs with names redacted and OSHA Form 300A Summary. * File extension must be PDF, Word or Excel

How is an accident and/or illness case recorded? *

Please describe your safety training program *

Do you have full-time safety representation on site when you have employees working? *

Yes

I understand that the Scope and General Safety Requirements requires weekly safety inspections. * Check 'Yes' to indicate your company agrees to adhere to CSM Group's weekly inspection policy for all projects awarded.

Other Attachments Please use to submit any additional items of your choosing, such as a company safety manual, additional financial information, letters of recommendation, applicable licenses/certifications, etc. * File extension must be PDF, Word or Excel

By submitting this form, you authenticate that the information provided is accurate and up-to-date.

Name *

Title *

Date *

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Trade Contractor Pre-Qualification Form