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State of North Carolina Prequalification for Single Prime Contractors 1. e. (2) Have any funds been expended by a surety company on your firm's behalf? LL Yes LL No If yes, explain: 1. e. (3) List all surety companies that have provided bonds for your company for the past five (5) years, provide explanation, required, if more than one company. Date Firm Reason Date Firm Reason Date Firm Reason Litigation /Claims 1. f. (1) Has your company been involved in any suits or arbitration proceedings within the last five years? LL No LL Yes If yes, please explain: 1. f. (2) Are there currently any judgments, claims, arbitration proceedings or suits involving Owners pending or outstanding against your company, its officers, owners, or agents? LL No LL Yes If yes, please explain: Insurance 1. g. In order to prequalify, firms must indicate that they can provide evidence of insurance coverage as follows, should they subsequently be the successful bidder. Have you attached a copy of your insurance certificate? LL Yes LL No • Worker's Compensation insurance as required by law and Employer's Liability Insurance coverage with minimum limits of $100,000. • General liability insurance with minimum limits of $500,000 per occurrence for bodily injury and $100,000 per occurrence /$300,000 aggregate for property damage. • Builder's risk at the full insurable value of the entire work site. Size /Capacity 1. h. (1) How many full -time permanent employees work for the company? 1. h. (2) If the company has more than one office location, how many full -time permanent employees work for the company at the location which will serve this project? _ 1. h. (3) List the annual dollar value of construction work the company has performed for each year over the last 5 calendar years (if applicable). Prequalification_Form_03 -01 -11 3 of 12 Attachment number 3 F -1 Page 66