Prequalification Form - MA

Company Address:
Mailing Address (if different from above):
Experience with Cutler:
Preferred Size of Contract/Order:
Number of Employees:
Design Build Capability:
BIM Capability:
Do you have at least the insurance limits as indicated in Exhibit 1:
General Liability:
Automobile Liability:
Excess Umbrella:
Workers Compensation Liability:
Statutory Limits:
Employer Liability Coverage:
Professional Liability Insurance (for a design-build firm):
Additional Insured on GL, Auto, and Excess Liability:
Waiver of Subrogation applies to all policies?:
List your firm's Worker's Compensation Interstate Experience Modifier Rate for the three most recent years:
Have you been cited by OSHA in the past three years?:
Are all of your employees OSHA 10-hour certified?:
Do you have a written safety program?:
Do you have a written hazard communications program?:
Do you have a full-time safety person?:
Please list 3 Major Projects, including Owner, General Contractor and total contract amount:
Project Owner General Contractor Contract Amount
Please list 3 Trade References and 1 Bank Reference:
Name Street City State Zip Code Contact Telephone Number