Contractor Qualification Form

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Page 1

After you complete the online form, you will be required to submit copies of the following:

Resume
Financial Statement
W-9
Insurance Certificates: Workers' Compensation & NYS Disability Benefits Insurance as required by New York State law - Comprehensive General Liability at least $500,000 for bodily injury (each occurrence) and $500,000 for property damage (each occurrence). However, contractors may opt to obtain $1,000,000 single limit liability coverage instead - Umbrella Insurance of at least $1,000,000 - Automobile Liability Insurance

Nassau/Suffolk License with photo
EPA Lead Paint Hazard Certificate

If qualified as a contractor, CDCLI will need to be named as additional insured and shall receive 30 days’ notice of any change, cancellation or non-renewal of any and all policies.

BIDDER INFORMATION

Legal Company Name

D/B/A

Address Line 1

Address Line 2

City

State

Postal Code

Business Phone Number

Email Address

BUSINESS

Structure

Corporation

Partnership

Individual

Other

State of Incorporation or Registration Number

Number of years in business

PRINCIPALS

List the name, address, telephone number, and position of each principal of the company. "Principal" means each officer and director of the bidder and each shareholder, partner and co-venturer who either controls or owns, directly or indirectly, a ten percent or greater interest in the bidder or who will actively participate in the performance by the bidder of the proposed contract.

Name	Address	Phone	Position

What type of licenses does your company hold?

Electrical

Plumbing

None

Other

Electrical Registration Number

Issued by

Date Issued

Plumbing Registration Number

Issued by

Date Issued

Other Registration Number

Issued by

Date Issued

If none, please explain

FINANCIAL REFERENCE

Name of Bank

Phone Number

Address Line 1

Address Line 2

City

Postal Code

State

Account Name

Account Number

Contact Person

WOMAN/MINORITY OWNED BUSINESS

Is this a woman or minority owned business?

YesNo

If yes, is it qualified with the State of New York?

YesNo

Certification Number

DISQUALIFICATION

Has this business, its individuals, partners, officers and/or shareholders been disbarred or otherwise disqualified from participation in city, state or federally funded work projects?

YesNo

If yes, please explain

AFFILIATION

List all other businesses in which the majority owners, partners, officers, and shareholders have held affiliation or interest in the past (5) years

Name of Business	Address	Work/Service Performed	Contact Person	Phone Number

PROFESSIONAL ABILITIES

Please list all types of home improvement projects that your firm is capable of performing such as: roofing, siding, heating systems, accessibility measures, insulation, windows, etc.

INSURANCE

Name of Insurance Company

Phone Number

Address Line 1

Address Line 2

City

State

Postal Code

Contact Person

Type of Coverage

Annual Premium

Are there any pending claims against your auto/general contractor liability coverage?

Yes

If yes, please let the amount for each claim.

Name of Bonding Company

Phone Number

Address Line 1

Address Line 2

City

State

Postal Code

Contact Person

PROGRAM PARTICIPATION

What programs would you like to participate in?

Hold shift key down to select mulitple

Please upload required documentation

Required documentation

Resume
Financial Statement
W-9
Insurance Certificates: Workers' Compensation & NYS Disability Benefits Insurance as required by New York State law - Comprehensive General Liability at least $500,000 for bodily injury (each occurrence) and $500,000 for property damage (each occurrence). However, contractors may opt to obtain $1,000,000 single limit liability coverage instead - Umbrella Insurance of at least $1,000,000 - Automobile Liability Insurance

Nassau/Suffolk License with photo
EPA Lead Paint Hazard Certificate

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