[ Builder's Company Name ]

[ Builder's Business Address ]

TRADE CONTRACTOR QUESTIONNAIRE

1.  General Company Information

Name:______________________________________________________________

Address:____________________________________________________________

City:______________________________ State:_________ Zip:________________

Telephone:___________________________ FAX:___________________________

(Check appropriate box.)

* Sole owner.  Name:__________________________________________________

* Partnership.  List names of partners:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

* Corporation.

President:__________________________________________________________

Vice President:______________________________________________________

Number of years in business under present name:_____________________________

Continued

1.  General Company Information (continued)

Trade(s) normally performed by company:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Number of trade and office personnel currently employed:

Trade employees:  _____________         Office employees:  _____________

2.  Financial Information

What is the maximum dollar value of work the company is capable of handling at one time?  	

$ _______________________________

Attach last 2 years audited financial statements at end of questionnaire.

3.  Insurance Information

What is the company's workers' compensation experience modification rate for the 3 most recent years?

19____  _________	    19____  _________		19____ _________

How much insurance coverage does the company currently carry?

				Yes	No		Amount

General Liability		___	___	      _____________
Automobile Liability		___	___	      _____________
Workers' Compensation		___	___	      _____________

4.  Safety Information

Does the company have a written safety program?    _____ Yes            _____  No

Use your OSHA Form 200 to complete the following table.

						19_____/19____/19____
Total Number of Workers' Compensation Claims	_______	______	_____
Number of Lost Time Workers' Comp. Claims	_______	______	_____
Number of Accident Liability Claims		_______	______	_____
Number of Fatalities				_______	______	_____

Continued

5.  Project Information

List current, ongoing projects with approximate dollar value and estimated completion date.

Project/Amount/Completion Date
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Has the company failed to complete any work assigned to it during the past 5 years?

________  Yes			________  No

If yes, explain:  								 		
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Attach a list of projects completed in the last 3 years and a list of builder references whom we may contact.

6.  Equipment Information

Attach a list of owned construction equipment with capacity, age, type, and attachments.

This questionnaire was completed by:

Name:______________________________________ Title:________________________

Signature:___________________________________  Date:___________________________