To prequalify as a subcontractor, please complete our online application form.

We need some basic information before starting. This will allow you to return to your form for future updates or to resume your application.

Your Email:


Your phone:

Name of Business:


Street Address:


City:


State:


Zip:


Phone Number:


Fax Number:


Main Contact:


Title:


Phone Number:


Email:


Alternate Contact:


Title:


Phone Number:


Email:


Company Website:

Type of Organization:

- Corporation
- Partnership
- LLC
- Sole Proprietor
- Other

if other please say:

State of Incorporation:


Date of Incorporation / Partnership / Organization:


Years in Business:
Certified:
- Large Business
- Small Business
- Minority Business
- Woman owned Business

Fed. ID or SS#:


No. Of Employees:


What other names has your organization operated under:


Is your organization owned or controlled by another organization:
- Yes
- No

If yes, List name(s):


List any affiliated organizations:

Average Annual Value of Work Completed ( 3 entries required )
Year: Average Dollar Value:
Year: Average Dollar Value:
Year: Average Dollar Value:
Year: Average Dollar Value:
Year: Average Dollar Value:

If requested prior to project award, are you willing to provide financial statements to be used, on a confidential basis, to evaluate your organizations financial strength?
- Yes
- No

Bidding Interest

Self-performed disciplines ( Please select from this list ): DIVISION 2 - Existing Conditions DIVISION 3 - CONCRETE DIVISION 4 - MASONRY DIVISION 5 - METALS DIVISION 6 - WOOD & PLASTIC COMPOSITES DIVISION 7 - THERM/MOIST PROTECTION DIVISION 8 - OPENINGS DIVISION 9 - FINISHES DIVISION 10 - SPECIALITIES DIVISION 11 - EQUIPMENT DIVISION 12 - FURNISHINGS DIVISION 13 - SPECIAL CONSTRUCTION DIVISION 14 - CONVEYING SYSTEMS DIVISION 21 - CONVEYING EQUIPMENT DIVISION 22 - FIRE SUPPRESSION DIVISION 23 - HEATING, VENTILATING, & AIR CONDITIONING DIVISION 25 - INTEGRATED AUTOMATION DIVISION 26 - ELECTRICAL DIVISION 27 - COMMUNICATIONS DIVISION 28 - ELECTRONIC SAFETY & SECURITY DIVISION 31 - EARTHWORK DIVISION 32 - EXTERIOR IMPROVEMENTS DIVISION 33 - UTILITIES DIVISION 34 - TRANSPORTATION DIVISION 35 - WATERWAY & MARINE CONSTRUCTION DIVISION 40 - PROCESS INTEGRATION DIVISION 41 - MATERIAL PROCESSING & HANDLING EQUIPMENT DIVISION 42 - PROCESS HEATING, COOLING & DRYING EQUIPMENT DIVISION 43 - PROCESS GAS & LIQUID HANDLING, PURIFICATION & STORAGE EQUIPMENT DIVISION 44 - POLLUTION & WASTE CONTROL EQUIPMENT DIVISION 45 - INDUSTRY-SPECIFIC MANUFACTURING EQUIPMENT DIVISION 46 - WATER & WASTEWATER EQUIPMENT DIVISION 48 - ELECTRICAL POWER GENERATION

Types of Projects:
- Residential
- Commercial
- Industrial
- Other

If other:


What geographical location(s) will you travel?


Desired Project Size: ( $$$ )
Minimum: Maximum:

Safety Information
Employee hours worked:
2011 -
2010 -
2009 -


Number of recordable injury / illness - OSHA Recordable Totals:
2011 -
2010 -
2009 -


Lost work day cases:
2011 -
2010 -
2009 -


Number of Fatalities on Jobsite:
2011 -
2010 -
2009 -


Restriced Duty / Lost Workday Incident Rate ( LWDIR )
2011 -
2010 -
2009 -


Total Incident Rate ( TIR ):
2011 -
2010 -
2009 -


Worker's Compensation Experience Modification Rate. ( EMR )
2011 -
2010 -
2009 -


Does your organization have a written safety program?
- Yes
- No

Does your organization have a written Substance Abuse Policy?
- Yes
- No

Have you recieved any regulatory ( EPA, OSHA, etc ) citations in the last 3 years, including Willful or Repeat violations?
- Yes
- No

Please attach OSHA 300 Logs from the previous 3 years:

Insurance Please attach a copy of your current Certificate of Insurance and fill out the following.

Carrier Name	Type of Coverage	Policy Dollar Limits
	General Liability
	Automobile
	Worker's Compensation
	Umbrella / Excess
	Professional Liability
	Pollution Liability

Agent Name:


Phone Number:


Are any of your aggregate limits of coverage for the current policy period impaired by claims?
- Yes
- No



Please note: Casey Industrial requires proof of insurance by certificate from all subcontractors prior to mobilication and such certificat shall be required to name Casey Industrial, Inc and the Owner as additional insured and also must contain a waiver of subrogation.

Bonding
Surety Company:


Agent Company:


Agent Contact:


Phone Number:


Bonding Capacity:


Single project Limit:

Bank Name:


Bank Contact:


Phone number:


Bank Address:

List all states in which your organization is licensed. Please make sure to list the unique state classification terminology. ( 1 required )

State	License No.	License Classification

List any code capabilities and / or code stamps held:

Please list any professional affiliations with any organizations. ( 1 required )
1.
2.
3.
4.
5.

Trade Reference ( 1 required )

Company:	Contact:	Phone No:
Company:	Contact:	Phone No:
Company:	Contact:	Phone No:

Project References ( 1 required )

Current Project:	Contact:	Phone No:
Scope:
Contract Value:	Completion Date:	General Contractor:

Current Project:	Contact:	Phone No:
Scope:
Contract Value:	Completion Date:	General Contractor:

Current Project:	Contact:	Phone No:
Scope:
Contract Value:	Completion Date:	General Contractor:

Current Project:	Contact:	Phone No:
Scope:
Contract Value:	Completion Date:	General Contractor:

In the last 5 years, has youe oganization failed to complete any work awarded?
- Yes
- No

In the last five years, have there been or are there currently any judgments, claims, or arbitration proceedings or suits pending or outstanding against your organization or its officers?
- Yes
- No

In the last 5 years has your organization filed any lawsuits or requested arbitration with regard to contracts? - Yes
- No

In the last 5 years has any prinicpal of your organization ever been an officer or principal of another organization when it failed to complete a contract? - Yes
- No

Completed By:


Title:


Phone Number:


Date: