Subcontractor FormPlease provide as much information as possible for us to review. Company Name Email * Phone * (###) ### #### Business Address If a corporation, what year were you established? Number of years under current ownership? If a partnership, date of organization: Type of Partnership? If a supplier, year company was established: Number of years under current ownership? Have you ever done business under any other name or business? 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: Text Thank you!
