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1General Information

2Organization

3Insurance Coverage Information

4Safety and Health Performance

5Safety and Health Programs and Procedures

6Work History

7Financial Information

8Bonding Information

General Information
NOTE: If you wish to start the form and return to complete at a later time, use the “Save & Continue Later” option. A custom link will be generated allowing you to return to your saved form. You must either copy this link or email to yourself; if you lose the link, please contact JTremblay@rhwhite.com.
Company Name:
Telephone:
Fax:
Street Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address (If different):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
E-Mail Address:
Date:
MM slash DD slash YYYY

1. Officers

President:
Vice President:
Chief Financial Officer:

2. How many years has your organization been in business under its present firm name?

Years

3. Parent Company Information:

Parent Company Name:
(if applicable)
Parent Company Address:
(if applicable)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent Company Telephone:
(if applicable)

4. Under Current Management Since (Date):

MM/YYYY

5. Bid Request Information:

Contact Name for Bid Requests:
Title:
Email address:
Telephone:

6. Form Completion Designee:

Pre-Qualification Form completed by:
Email address:*
Telephone:

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Insurance Coverage Information

R. H. White's insurance requirements may be viewed at Certificate of Liability insurance sample.

The following are insurance requirements which are MANDATORY for all subcontractors.

*General Liability Minimum Coverage*	$1,000,000 Each Occurrence $2,000,000 General Aggregate $2,000,000 Products Completed Operations Aggregate Aggregate limit to apply Per Project only. We will not accept per Policy or per Location. Additional insured coverage to be Primary and Noncontributory. Waiver of Subrogation must apply.
Auto Liability Minimum Coverage	$1,000,000 Combined Single Limit – on Any Auto Additional insured coverage to be Primary and Noncontributory. Waiver of Subrogation must apply.
Workers Compensation Statutory Limits	$1,000,000 Waiver of Subrogation must apply. *All* subcontractors and their employees working on R. H. White’s project jobsites must be covered with Workers Compensation INCLUDING sole proprietors and owners of LLCs that may have chosen exemption.
Umbrella Liability Coverage	$5,000,000 Each Occurrence* $5,000,000 Aggregate* *These limits may be reduced at RHW's discretion. Additional insured coverage to be Primary and Noncontributory. Waiver of Subrogation must apply.
Pollution Liability Coverage	$5,000,000 *(if environmental risks or any handling of hazardous material). Limit may vary depending on exposure/liability.

In Description of Operations section of certificate, insert the following required wording:

For Prequalification Purposes - R.H. White Construction Co., Inc. and any person or entity or organization required to be named an additional insured by reason of any contract or agreement with R.H. White Construction Co., Inc. shall be and is deemed a primary additional insured on a non-contributory basis under all commercial general liability, automobile liability and commercial umbrella liability policies of Subcontractor. Additional Insured endorsements required are CG 20 10 11 85 or CG 2010 (10/93) and CG 20 37 or CG 2033 and CG 2037 or an endorsement providing equivalent coverage to the additional insureds. Each policy will be endorsed to provide 30 days' notice of cancellation to RH White Construction Co., Inc. Waiver of Subrogation applies to all policies.

In Certificate Holder area, insert:
R. H. White Construction Co., Inc.
41 Central Street
Auburn, MA 01501

Provide a copy of your certificate of insurance showing coverage based on RHW’s Insurance Requirements with a copy of the Additional Insured endorsements (CG 20 10 11 85 or CG 2010 (10/93) and CG 20 37 or CG 2033 and CG 2037 or equivalent)

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General Information

Organization

Insurance Coverage Information

Safety and Health Performance

Safety and Health Programs and Procedures

Work History

Financial Information

Bonding Information

Contractor Evaluation

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