Federal Tax ID #*
Type of Company*
Number of Employees*
Average work in place during last 5 years*
Work Under Contract*
Average project size in place last year*
Size of Projects Preferred*
Project Location Preferred*
Does the company have offices, plants or warehouses at other locations?* YesNo
If yes, list addresses:
Are you able to bond projects?* YesNo
Single Project Limit*
Worker’s Compensation Experience Modifier:
Current Experience Modifier*
Effective Date (Month and Year)*
You are required to verify your current workers’ compensation experience modifier. If your experience modifier is .90 or higher, you may be asked to provide a copy of additional information for up to the past four years.
General Liability Limits:
Does the company have a line of credit from any lending institution? YesNo
Please list the Lender's name and address, as well as, the Lending Officer's name and phone number.
Lending Officer's Name:
Lending Officer's Phone Number:
List four (4) representative projects completed in the last five (5) years.
Name of Project:
Contact Phone Number:
List four (4) representative projects currently under construction.
List three (3) of your subcontractors of suppliers.
List three (3) clients.
Does the company...
Enviromental Mission Attachment:
Reduction and Recycling Program Attachment:
In the past five years, has the company...
Give details for any yes answer.
Contractor's License No.
Copy of all Contractor’s License:
Audited or Reviewed Financial Statements:
Internal Financial Statements:
Any additional information: