Contractor Qualification Form

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Required Documents

Thank You!

Your submission has been received. If you'd like to start the qualification process right away, you may continue to the next page.

After you complete the form, you will be required to submit copies of the documents below.

All Programs

Resume
Financial Statement
W-9
EPA Lead Paint Hazard Certificate
EPA Lead Paint Renovator
Insurance certificates: Workers' Compensation & NYS Disability Benefits Insurance as required by New York State law

HIO Additional Required Documentation

Insurance Certificates:

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

Nassau/Suffolk License with photo

If qualified as contractor, CDLI 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.

ADU Plus One Program Additional Required Documentation

Insurance Certificate: Comprehensive General Liability at least $500,000
Suffolk / Town of Southampton / Town of Shelter Island License with photo
References

If qualified as a contractor, CDLI, the State of New York, and The Housing Trust Fund Corporation 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.

VENDOR INFORMATION

BIDDER INFORMATION

Legal Company Name

D/B/A

Street Address

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.

First Name

Last Name

Position

Phone

Street Address

City

State

Zip/Postal Code

What type of licenses does your company hold?

ElectricalPlumbingNoneOther

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

Street Address

City

State

Postal Code

Account Name

Account Number

Contact Person

WOMAN/MINORITY OWNED BUSINESS

Is this a woman owned business?

YesNo

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

YesNo

Certification Number

Is this a minority owned business?

YesNo

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

YesNo

Certification Number

Veteran Owned Business

Is this a service disabled veteran owned business?

YesNo

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

Street Address

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

Street Address

City

State

Postal Code

Contact Person

PROGRAM PARTICIPATION

What Home Improvement and Optimization programs would you like to participate in?

What ADU programs would you like to participate in?

Babylon Plus One ADUSouthampton Plus One ADUShelter Island Plus One ADU

Form Submitted By

First Name

Last Name

Title

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