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Bid Application

Step 1 of 4

25%

General Information

Company Name(Required)

Date of Response(Required)

Phone(Required)

Fax

Email(Required)

Main Office Address(Required)

Street Address City State ZIP Code

Website(Required)

Do you employ more than 10 employees?(Required)

Yes

No

What is the average number of employees on your payroll for the last three years?

Year(Required)

Number(Required)

Please enter a number from 11 to 9999.

Number(Required)

Please enter a number from 11 to 9999.

Year(Required)

Year(Required)

Number(Required)

Please enter a number from 11 to 9999.

Ownership(Required)

Sole Proprietorship

Partnership

Corporation

Other

Year Company Started(Required)

Please enter a number from 1900 to 2021.

Main Office Contact

Name(Required)

Officer 1 Name

Position(Required)

Officer 1 Position

Email(Required)

Officer 1 Email

Phone(Required)

Officer 1 Phone

Fax

Officer 1 Fax

Name(Required)

Officer 2 Name

Position(Required)

Officer 2 Position

Email(Required)

Officer 2 Email

Phone(Required)

Officer 2 Phone

Fax

Officer 2 Fax

Geographic Work Areas - Local Area Name

Name(Required)

Work Scope

Work Scope Details(Required)

Safety Information

Current experience modifications rate (EMR) (Obtained from insurance carrier) rates

Year

Please enter a number from 1900 to 2021.

EMR Rates

Year

Please enter a number from 1900 to 2021.

EMR Rates

Year

Please enter a number from 1900 to 2021.

EMR Rates

OSHA 300 Log Information

Reporting Year(Required)

Number of lost and restricted workday cases(Required)

Please enter a number from 0 to 999.

Employee hours worked(Required)

Please enter a number from 0 to 9999.

Description(Required)

How many OSHA violations has this company received this reporting year?(Required)

Please enter a number from 0 to 999.

Recordable incidence rate(Required)

Please enter a number from 0 to 999.

Lost workday incidence rate(Required)

Please enter a number from 0 to 999.

If these violations were willful, please provide a description

Reporting Year(Required)

Number of lost and restricted workday cases(Required)

Please enter a number from 0 to 999.

Employee hours worked(Required)

Please enter a number from 0 to 9999.

Description(Required)

How many OSHA violations has this company received this reporting year?(Required)

Please enter a number from 0 to 999.

Recordable incidence rate(Required)

Please enter a number from 0 to 999.

Lost workday incidence rate(Required)

Please enter a number from 0 to 999.

If these violations were willful, please provide a description

Reporting Year(Required)

Number of lost and restricted workday cases(Required)

Please enter a number from 0 to 999.

Employee hours worked(Required)

Please enter a number from 0 to 9999.

Description(Required)

How many OSHA violations has this company received this reporting year?(Required)

Please enter a number from 0 to 999.

Recordable incidence rate(Required)

Please enter a number from 0 to 999.

Lost workday incidence rate(Required)

Please enter a number from 0 to 999.

If these violations were willful, please provide a description

OSHA 30 certified personnel

Name

Phone

Email

OSHA 100 certified personnel

Name

Phone

Email

Safety Questionnaire

Does your company have a qualified person responsible for safety within yoru company?(Required)

Yes

No

Please describe his/her qualitifications:(Required)

Does this person do safety inspections on all of your projects?(Required)

Yes

No

How often are these inspections?(Required)

Daily

Weekly

Monthly

Quarterly

Annualy

Has your company ever implemented 100% fall protection?(Required)

Yes

No

If requested, can you provide us with a site-specific program addressing the fall hazards in your company's work?(Required)

Yes

No

Does your company have a written company safety policy and program and will you provide copies if requested?(Required)

Yes

No

Does your company require documented safety meetings for your employees?(Required)

Yes

No

How often are these safety meetings?(Required)

Daily

Weekly

Monthly

Quarterly

Annualy

N/A

Does your company provide safety training for all employees?(Required)

Yes

No

Describe the training provided(Required)

Does your company set annual safety training goals?(Required)

Yes

No

Please list examples of training goals(Required)

Does your company have a program recognizing your employees for safety excellence?(Required)

Yes

No

Does your company have a disciplanary program in place for safety violations?(Required)

Yes

No

Does your company conduct accident/incident investigations?(Required)

Yes

No

Does your company have a substance abuse policy?(Required)

Yes

No

Please indicate which are included in your policy(Required)

Pre-hire/initial employment

Cause

Post-accident/incident

Random

Periodic

Does your company have a return to work/light duty program?(Required)

Yes

No

Insurance Information

Does your carry workers' compensation insurance?(Required)

Yes

No

What is the policy number?(Required)

What is the expiration date?(Required)

Signature

We have attempted to answer all questions in a full and complete manner to assure that our answers are not in any respect misleading, either by expressing ourselves in a misleading or ambiguous manner or omitting information. We recognize that MV Commercial Construction will be relying on the accuracy of the information and our responses in this questionnaire in deciding whether to permit us to bid and in awarding work to our Company.

Name of Company(Required)

Completed By(Required)

Title(Required)

Date(Required)

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