Subcontractor Form Please provide as much information as possible for us to review. Company Name: Your email address: Business Address Street Address: City: State Zip Code: Type of Business If a CORPORATION, what year were you established?: Number of years under current ownership? If a PARTNERSHIP, Date of organization: Type of PARTNERSHIP: EITHER (GENERAL, LIMITED, OR ASSOCIATION) If a SUPPLIER, Year Company was ESTABLISHED: Number of years under current ownership? Have you ever done business under any other name or business? If Yes, please list all names. BANK REFERENCES Bank name: Street Address: City: State: Zip Code: Telephone: Fax: Email: INSURANCE: COVERAGE TYPE LIMITS Workmen’s Compensation: General Liability: Excess / Umbrella Liability: Automobile Liability: WORK IN PROGRESS: Job #1: Location of job site: Contract Amount: Job #2: Location of job site: Contract Amount: Job #3: Location of job site: Contract Amount: SAFETY: List your company’s Interstate Experience Rating Modifier (EMR) for the last 3 years: 2017 Year RATING 2016 Year RATING 2015 Year RATING List your company’s number of injuries/illnesses from your OSHA 300 logs for the 3 most recent years. 2017 Year RATING 2016 Year RATING 2015 Year RATING COMPANY SAFETY CONTACT Name: Contact Phone Number Contact Email Address OSHA Inspections Have you been inspected by OSHA within the last 3-years? If so, were these inspections response a complaint? Have you been cited as a result of these inspections? If yes, describe the citations:    We will follow up with additional information if required, Please allow us 2-5 business days to review your submission.