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State of North Carolina <br />Prequalification for Single Prime Contractors <br />Litigation /Claims <br />2. f. (1) Has your company ever failed to complete work awarded to it? LL Yes LL No <br />If yes, please provide project name(s), contact information for owner and architect, year(s), and reason why. Attach <br />relevant documentation. <br />2. f. (2) Have you ever paid liquidated damages on any project? LL Yes LL No If yes, state the project name(s), year(s), <br />and reason why. <br />2. f. (3) Has your company filed any claims with the North Carolina State Construction Office within the last five years? <br />LL Yes LL No If yes, state the project name(s), year(s), case number, and reason why. <br />2. f. (4) Has your present company, its officers, owners, or agents ever been convicted of charges relating to conflicts of <br />interest, bribery, or bid - rigging? LL Yes LL No If yes, state the project name(s), year(s), and reason why: <br />2. f. (5) Has your present company, its officers, owners, or agents ever been barred from bidding public work in North <br />Carolina? LL Yes LL No If yes, state the project name(s), year(s), case number and reason why: <br />Safety Record <br />2. g. List your company's Experience Modification Rate (EMR) for past three years. (Attach OSHA 300 Log for the last 3 <br />years.) Have you attached OSHA 300 log? LL Yes LL No <br />Present Rate Last Rate Year before rate <br />If these rates reflect corporate performance over a number of locations, please explain, to the extent possible, the <br />performance experience of the location serving this project: <br />List any OSHA fines and job site fatalities in the past 3 years with an explanation: <br />Historically Underutilized Business (HUB) Plan <br />2. h. (1) Does the company currently have a documented plan for engaging subcontractor participation from Historically <br />Underutilized Businesses? LL Yes LL No If yes, please attach your company's HUB Plan. <br />2. h. (2) What has been your company's typical percentage level of Historically Underutilized Business participation for <br />similar projects in North Carolina for the past 5 years? <br />Prequalification_Form_03 -01 -11 8 of 12 <br />Attachment number 3 <br />F -1 Page 71 <br />