SUBCONTRACTOR/VENDOR PRE-QUALIFICATION

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENTGENERAL COMPANY INFORMATIONCompany’ Legal NameMailing AddressStreet AddressPhoneFax:www.xyzcorp.bizWebsiteEstimating ContactTitle:E-Mail AddressYear Company Founded: Partnership CorporationType of Company LLC Other Sole Proprietor YesAre there any affiliated subsidiaries?If yes, please name them YesIs your firm owned or controlled by anotherorganization?If yes, name of parent organizationWashington State Contractors License No.Washington State Sales Tax Registration No.Washington State Unemployment Insurance No.Federal Tax ID No. YesAre you an Union contractorIf yes, please list Unions which you have agreements with:Total number of current employeesHow many employees:Office PersonnelField Labor WBE MBE No NoExp: NoField Supervision DBEMinority Business Enterprise Status:Certifying Agency:* Please attach copies of all certifications regarding your MBE status 10k - 250k 251 - 500k 500k Preferred Project SizeList the geographical areas in whichyou work:List the trades you normally performwith your own forces:What percentage of your company’swork is subcontracted?%

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENTCONTRACTOR’S LICENSE(S) AND NUMBERSCityLicense No:CityLicense No:CityLicense No:CityLicense No:CityLicense No:COMPANY’S PRINCIPALSName:Name:Name:Name:SURETY INFORMATIONCurrent Surety CompanyBroker / Agent NameBond RatesTitle:Title:Title:Title:Single Project Bonding CapacityAggregate Bonding CapacityVolume 100,000 – 500,000 – 1M Bond % RateSAFETY INFORMATIONCompany Safety Professional:Title:Telephone:Email:Total # of full time employees:Total # of Part time employees:OSHA 300 Information (Entire Company) Most recent 3 yearsOSHA Recordable Incident RateLost Time Incident RateNumber of Recordable Injury CasesNumber of Lost Time Incidents/IllnessesNumber of Days Away from WorkNumber of Fatalities

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENTTotal Employee Hours WorkedOSHA CITATIONSHas your company received any OSHA citations in the lastthree (3) years? If yes, please provide the date ofviolations, the violation type, (i.e. serious), and what hasbeen done to prevent similar violations.SAFETY GOALS AND OBJECTIVESDo you have company safety goals and objectives?Do you have a written safety and health program/manual? Yes No Yes Yes No No Yes No Yes No Yes No*Please note that UNIMARK Construction reserves the right to review this document upon requestSAFETY MEETINGSDo your supervisors/superintendents hold safety meetings?If yes, how often?INSPECTIONSDo you conduct field safety inspections to determinecompliance with applicable federal, state, local, andcompany regulations/procedures?If yes, who conducts the inspections?Are inspection reports generated?SAFETY TRAINING AND ORIENTATION Yes NoDo you have a documented pre-job or new employeeoccupational safety and health program? Yes NoDo you have a documented occupational safety & healthtraining program for newly hired or promoted first linesupervisors or foremen?If yes, who conducts this training (name. title)?Please check all elements below that are delivered by your trainingprogram: Yes NoSubjectInjury/Incident/Near-Miss Yes NoEmergency Procedures Yes NoFirst Aid Procedures Yes NoHazard Recognition Yes NoIncident Reporting Yes No Yes NoJob Hazard Analysis Yes NoRespiratory Protection

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENTLunch Box Safety MeetingsOther (Please Specify)Does you company hold regularly scheduled safetymeetings for all employees?If yes, how often?DRUG FREE WORKPLACEDoes your company have a Drug Free Workplace Program?Does this program include the following testing:Pre-EmploymentRandomPost IncidentReasonable SuspicionINJURY/INCIDENT INVESTIGATIONDoes your company conduct injury, incidents, and nearmiss investigations?Who conducts the investigations (name, title)? No No No Yes Yes Yes Yes YesYesYesYes Yes No NoNoNoNo NoLITIGATION INFORMATION (Please attach additional pages if necessary) Yes NoDoes your company have any outstanding judgments orclaims against it?If yes, please explain: Yes NoHave any of the Owners, officers, or major stockholders ofyour company ever been indicted or convicted of anyfelony or other criminal conduct?If yes, please explain: Yes NoHas your company or any of its Owners, officers, or majorstockholders ever been suspended, disbarred, or otherwiseprecluded from pursuing public work or ever been found tobe non-responsive to a public agency?If yes, please explain: Yes NoHas your company or any of its principals ever petitionedfor bankruptcy or failed in business?If yes, please explainIn the past five (5) years has your company been involved with any of the following: NoA claim made against it for improper, delayed, defective, or Yesnon-compliant work or failure to meet warranty issues?If yes, please explain: Yes NoBeen assessed liquidated damages?

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENTIf yes, please explain:Defaulted or failed to complete a contract?If yes, please explainBeen terminated from a contract?If yes, please explainHad your license revoked or suspended?If yes, please explainHad any labor law violations?If yes, please explain: Yes No Yes No Yes No Yes NoINSURANCE INFORMATION (Please attach a copy of you Insurance Certificate)Insurance Broker Name:Phone Number:Please review the attached Vendor Insurance Requirement Checklist to verifywhether or not you meet UNIMARK Construction Group’s minimum insurancerequirements.We have reviewed the attached Vendor Insurance Requirement Checklist and wefully comply with UNIMARK Construction Group’s insurance requirements: Yes NoIf you checked NO, please list which requirements you do NOT meet:REFERENCESPlease list three (3) customer references and three (3) credit referencesCUSTOMER REFERENCESCompany Name:Contact Name:Title/Position:Phone Number:Email:Company Name:Contact Name:Phone Number:Title/Position:Email:Company Name:Contact Name:Phone Number:Title/Position:Email:CREDIT REFERENCESCompany Name:

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENTContact Name:Phone Number:Title/Position:Email:Company Name:Contact Name:Phone Number:Title/Position:Email:Company Name:Contact Name:Phone Number:Title/Position:Email:KEY FINANCIAL INFORMATIONCurrent Year Revenues Total Assets Current Liabilities Total Liabilities Net Equity Current Backlog Average Monthly Billings No YesHas your firm filed Bankruptcy?If yes, please explain: No YesDo you have a D&B number:If yes, please list your number:D&B Pay IndexPlease attach a copy of your latest audited financial statement (please note that yourfinancial statement is strictly for UNIMARK Construction Group use and will betreated with the utmost confidentiality).Name of your Bank:Address:Phone:Contact Person:Title/PositionAmount of line of credit: Amount Available: Expiration Date:RELEVANT EXPERIENCEPlease attach a list of current major projects giving the name of the project, owner,general contractor, architect, scope of work, and scheduled completion (pleaseinclude contact information including name and phone number)Please attach a list of major projects completed in the past five (5) years giving thename of the project, owner, general contractor, architect, scope of work, and

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENTscheduled completion (please include contact information including name and phonenumber)In order for your company to be considered for approval as a subcontractorfor UNIMARK Construction Group, LLC please be sure to attach the followingto your completed application: Sample Certificate of InsuranceLatest Audited Financial StatementCurrent Relevant ExperiencePast Relevant ExperienceCONTRACTORS STATEMENT OF VALIDITYWe have attempted to answer all questions in a full and complete manner to assurethat our answers are not in any respect misleading either by expressing ourselves ina misleading or ambiguous manner or by omitting information. We recognize thatUNIMARK Construction Group will rely on the accuracy of the information and ourresponses in this questionnaire in determining whether to permit us to bid upcomingwork as well as in awarding work to our company.Dated atName of CompanyCompleted by:Title: (must be on officer of the company)thisday of Two Thousand andTitle:being duly sworn deposes and says that theinformation provided herein is true and sufficiently complete so as to not bemisleading.Subscribed and sworn before me thisDay of, 20Notary Public:My Commission Expires:

UNIMARK – INSURANCE CERTIFICATE CHECKLISTSUBCONTRACTOR NAME:PROJECT NO:The ACCORD Certificate of Liability does not provide information to us as to policy restrictions, exclusions or limitations incoverage which may cause a material breach under your contract agreement.Commercial General Liability:COVERAGE DOES INCLUDE:YES 2,000,000 General Aggregate Limits 2,000,000 Products & Completed Operations 1,000,000 Each OccurrenceStop Gap Liability Included - 1,000,000 LimitsPer Project Aggregate Box CheckedUnimark Construction is named as an Additional InsuredPrimary Additional Insured EndorsementNon Contributory Additional Insured EndorsementWaiver of Subrogation EndorsementAdditional Insured Covers Ongoing OperationsAdditional Insured Covers Completed OperationsAdditional Insured includes “arising out of ” languageCopies of All Forms and Endorsements Are Attached to the CertificateCommercial Auto Insurance 1,000,000 Combined Single LimitsHired Auto Liability Box CheckedUmbrella Liability Insurance 1,000,000 Per Occurrence 1,000,000 AggregateAdditional Insured and Waiver of Subrogation Boxes CheckedGeneral LiabilityAutomobile LiabilityReviewed By:Date:NO

SUBCONTRACTOR/VENDOR PRE-QUALIFICATION STATEMENT CONTRACTOR’S LICENSE(S) AND NUMBERS CityLicense No: CityLicense No: CityLicense No: CityLicense No: CityLicense No: COMPANY’S PRINCIPALS Name:Title: Name:Title: Name:Title: Name:Title: SURETY INFORMATION Curre