Subcontractor Vendor Application – G&G Enterprises Construction Corp

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Subcontractor Pre-qualification Form

Subcontractor Company Information
Federal Employer ID Number*
Legal Company Name*
Company DBA*
Date Founded*
Business Type*
- Individual
- Corporation
- L.L.C.
- Partnership
- Joint Venture
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Scope of Work your company performs*
Type of Minority Contractor*
- MBE
- WBE
- N/A
HUB Certified Contractor*
- Yes
- No
- N/A
No. of Office Employees*
No. of Field Employees*
Contact Name*
Title*
Email*
Web Address*
Insurance
Name of Insurance Agency*
Contact Person*
Phone Number*
General Liability Carrier*
Automobile Liability Carrier*
Excess or Umbrella Liability Carrier*
Worker's Compensation Carrier*
Must meet the following requirements:
- General aggregate per project
- Certification issued on standard ACORD form
- Coverage supplied on a primary and non-contributory basis (GL & Auto)
- Waiver of subrogation in favor of additional insureds (GL, Auto & W/C)
- G&G Enterprises Construction Corp shown as Certificate holder
- G&G Enterprises Construction Corp, project owner (and lender if required) shown as additional insured
- Cancellation requires 30 days written notice
General Liability Coverage Minimums:
General Aggregate $1,000,000*
- Yes
- No
$ Amount*
Products-Comp/Op Agg. $1,000,000*
- Yes
- No
$ Amount*
Personal & Adv Injury $1,000,000*
- Yes
- No
$ Amount*
Each Occurrence $1,000,000*
- Yes
- No
$ Amount*
Fire Damage $50,000*
- Yes
- No
$ Amount*
Medical Expense $5,000*
- Yes
- No
$ Amount*
Automobile Liability Coverage Minimums:
Combined single limit $1,000,000*
- Yes
- No
$ Amount*
Excess or Umbrella Coverage Minimums
Each occurrence $1,000,000*
- Yes
- No
$ Amount*
Workers Compensation Minimums
Each accident $500,000*
- Yes
- No
$ Amount*
Disease policy limit $500,000*
- Yes
- No
$ Amount*
Disease each employee $500,000*
- Yes
- No
$ Amount*
**Current Insurance Certificate showing your limits must be attached***
Max. file size: 256 MB.
Please do not reference G&G Enterprises Construction Corp
Safety
Does your firm have a written Field Safety Program?*
- Yes
- No
Does your firm have a full time, on staff, Safety Director?*
- Yes
- No
Does your firm hold site safety meetings for Field Supervisor(s)?*
- Yes
- No
Does your firm hold site safety meetings for Field Employee(s)?*
- Yes
- No
Does your firm hold site safety meetings for New Hire(s)?*
- Yes
- No
Does your firm hold site safety meetings for Subcontractor(s)?*
- Yes
- No
Does your firm hold site safety meetings for site safety inspections?*
- Daily
- Weekly
Name of Inspector*
Title*
Legal
Is your firm a party to any labor agreements?*
- Yes
- No
Is your firm currently involved in any lawsuits?*
- Yes
- No
Taxpayer Identification Number
Name as Shown on income tax return*
Taxpayer Identification Number*

SS or EIN
Under penalties of perjury, I certify that: *
1. The number shown on this form is my correct taxpayer identification number and
2. I am not subject to backup withholding because:(a) I am exempt from backup withholding, or(b) I have not been notified by the IRS. I am subject to backup withholding as a result of a failure to report all interest or dividends, or(c) the IRS has notified me I am no longer subject to withholding; and
3. I am a U.S. citizen or other US person.
I agree to the terms & conditions.
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CONTACT

voice 409/883.5465
fax 409/883.9132
accounting@gandgenterprises.com

OPERATIONS

3260 Eastex Freeway
Beaumont, TX 77703

FIELD SUPPORT SERVICES

3410 Lutcher Drive
Orange, TX 77630

EXECUTIVE

501 Procter Street, Suite #322
Port Arthur, TX 77640