New Subcontractor Registration

Please provide all required information to register your business with Danella Companies, Inc. as a subcontractor.

Step 1 of 7

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Subcontractor Representations

If for any reason a representation on this questionnaire is not accurate and complete as of the time the subcontractor signs this form, the subcontractor must identify the provision and explain the reason in detail on a separate sheet. Absent such an explanation, the Subcontractor represents that the following statements throughout this entire application are complete and accurate. The following questions apply to (i) Subcontractor, Subcontractor’s parent, subsidiaries, and affiliates (if any); (ii) any joint venture (including its individual members) and any other form of partnership (including its individual members) which includes Subcontractor or Subcontractor’s parent, subsidiaries, or affiliates; (iii) Subcontractor’s directors, officers, principals, managerial employees, and any person or entity with a 10% or more interest in Subcontractor; (iv) any legal entity, controlled, or 10% or more of which is owned, by Subcontractor, or by any director, officer, principal, managerial employee of Subcontractor, or by any person or entity with a 10% or more interest in Subcontractor. (If the answer to any question is “YES,” Subcontractor must provide all relevant information on a separate sheet)

Within the past five (5) years, has Subcontractor been declared not responsible to receive a public or private contract?(Required)

Yes

Has Subcontractor been debarred, suspended, or otherwise disqualified from bidding, proposing, or contracting?(Required)

Yes

Is there a proceeding pending relating to Subcontractor’s responsibility, debarment, suspension, or qualification to receive a public or private contract?(Required)

Yes

Within the past five (5) years, has Subcontractor defaulted on a contract or been terminated for cause on a public or private contract?(Required)

Yes

Has a public or private entity requested or required enforcement of any of its rights under a surety agreement on the basis of Subcontractor’s default or in lieu of declaring Subcontractor in default?(Required)

Yes

Within the past five (5) years, has the Subcontractor been required to engage the services of an Integrity Monitor in connection with the award of or in order to complete any public or private contract?(Required)

Yes

Within the past (5) years, have Subcontractor’s safety practices/procedures been evaluated and ruled as less than satisfactory by a public or private entity?(Required)

Yes

Has Subcontractor’s Workers’ Compensation Experience Rating (also known as the Experience Modification Rate or EMR) been 1.2 or greater at any time in the last five (5) years? If yes, please explain.(Required)

Yes

Within the past five (5) years, has the Subcontractor been accused of violating equal opportunity or nondiscrimination laws?(Required)

Yes

Within the past five (5) years, has the Subcontractor been accused of violating prevailing wage laws, regulations, or executive orders?(Required)

Yes

Upload Explanation to any "YES" Answers above

Max. file size: 2 GB.

Subcontractor Representations (Continued)

Within the past ten (10) years has been convicted of or pleaded nolo contendere to (i) any felony or (ii) a misdemeanor related to truthfulness in connection with business conduct.(Required)

Yes

Is currently disqualified from selling or submitting bids/proposals to or receiving awards from or entering into any contract with any federal, state, or local government agency, any public authority or any other public entity.(Required)

Yes

Has within a ten (10) year period preceding the date of this Questionnaire been convicted of or had a civil judgment rendered against it for or in relation to: (i) commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; (ii) collusion with another person or entity in connection with the submission of bids/proposals; (iii) violation of federal or state antitrust statutes or False Claims Acts; or (iv) commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.(Required)

Yes

In the past ten (10) years, has Subcontractor entered into a consent decree, deferred prosecution agreement or a non-prosecution agreement?(Required)

Yes

In the past seven (7) years, have any bankruptcy proceedings been initiated by or against the Subcontractor (whether or not closed) or is any bankruptcy proceeding pending by or against the Subcontractor regardless of the date of filing?(Required)

Yes

In the past five (5) years, have there been any judgments or tax liens of $100,000 or more, including but not limited to judgments based on taxes owed, fines and penalties assessed by a government agency against Subcontractor at any time?(Required)

Yes

During the past five (5) years, has the Subcontractor failed to file any applicable federal, state, or local tax return?(Required)

Yes

Upload Explanation to any "YES" Answers above

Max. file size: 2 GB.

Financial History

Three Year Business Revenue

Year Ending

Revenue

Bonding Capacity

Enter a Dollar Value

Upload Most Recent Financial Statement

Max. file size: 2 GB.

Insurance Information

Insurance Broker/Producer Name(Required)

Insurance Broker/Producer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Broker/Producer Contact

First Name Last Name

Insurance Broker/Producer Contact Phone Number

Insurance Broker/Producer Contact Email(Required)

Upload Certificate of Insurance(Required)

Max. file size: 2 GB.

Certificate Holder/Additional Insured fields do not need to be completed at this time.

Safety Information

Calendar Year Reported(Required)

What is the Experience Modification Rate (EMR)?(Required)

How many DOT Violations?(Required)

How many OSHA Violations?(Required)

How many Environmental Violations?(Required)

How many Recordable Incidents?(Required)

How many Total Hours Worked?(Required)

What is your Total Recordable Incident Rate (TRIR)?(Required)

Upload: OSHA Form 300 Log (required annually)(Required)

Drop files here or

Max. file size: 2 GB.

Please attach a blank document if not applicable

Upload: EMR Letter (required annually)(Required)

Drop files here or

Max. file size: 2 GB.

Please attach a blank document if not applicable

Explain how safety and quality is managed/enforced within your company(Required)

Please type “see attached” if you will be providing an attachment

Do you have a written safety and quality program?(Required)

Yes

If, yes upload your safety and quality program.(Required)

Drop files here or

Max. file size: 2 GB.

Do you conduct criminal history checks?(Required)

Yes

Do you employ anyone, or hire individuals, whose criminal background check revealed felony or misdemeanor convictions within the last ten (10) years?(Required)

Yes

Do you check your employees against the National/State Sex Offender Registry to yield a national and all-states search?(Required)

Yes

Do you verify employee’s citizenship, most recent country of permanent residence, and legal right to work in the jurisdiction inwhich the employee will be working?(Required)

Yes

Are all employees provided with formal safety training as applicable to their work and current regulations?(Required)

Yes

Do you require a new employee orientation and onboarding session for all employees?(Required)

Yes

Do you have a PPE (Personal Protective Equipment) Policy?(Required)

Yes

If yes, upload a copy of your PPE policy.(Required)

Drop files here or

Max. file size: 2 GB.

Do you have an incident reporting and investigation procedure?(Required)

Yes

If yes, upload a copy of your incident reporting and investigation procedure.(Required)

Drop files here or

Max. file size: 2 GB.

Do you have a near-miss reporting program?(Required)

Yes

Do you have a Job Safety Analysis or Task Hazard Analysis program in place?(Required)

Yes

If so, please provide a copy of the Job Safety Analysis of Task Hazard Analysis form utilized by your employees(Required)

Drop files here or

Max. file size: 2 GB.

Are regular safety meetings held, and documented, on project sites? If so, list the contact information below(Required)

Yes

Do you have personnel trained in first aid and CPR on-site at each job location?(Required)

Yes

Do you maintain a substance abuse program?(Required)

Yes

Safety Lead Contact(Required)

First Name Last Name

Safety Lead Contact Title(Required)

Safety Lead Contact Email(Required)

Safety Lead Contact Phone(Required)

Safety Programs File Upload(Required)

Drop files here or

Max. file size: 2 GB.

Operations Information and References

How would you describe your company?(Required)

Large General Contractor

Small General Contractor

Subcontractor

Supplier/Vendor

Please provide a summary of the services your company provides(Required)

Do you self perform all work, use subcontractors, or both?(Required)

Self Perform

Subcontract

What is the Labor Affiliation of your workforce? Select all that apply(Required)

Union

Non-Union

Open Shop

Prevailing Wage

Please list the states in which your company performs work(Required)

Do you hold licenses in any of these states? If so, which ones and what license?(Required)

Provide information on all company locations (Activity/Operation, City/State, and FTEs from each location)(Required)

References and Customer History

For which companies have you performed work?(Required)

Reference #1(Required)

First Name Last Name

Reference #1 – Company Name(Required)

Reference #1 – Email(Required)

Reference #1 – Phone

Reference #1(Required)

Last 3 Year Total Sales w/ This Customer

% of Total Company Volume

Reference #2(Required)

First Name Last Name

Reference #2 – Company Name(Required)

Reference #2 – Email(Required)

Reference #2 – Phone Number(Required)

Reference #2(Required)

Last 3 Year Total Sales w/ This Customer

% of Total Company Volume

Reference #3(Required)

First Name Last Name

Reference #3 – Company Name(Required)

Reference #3 – Email(Required)

Reference #3 – Phone Number(Required)

Reference #3(Required)

Last 3 Year Total Sales w/ This Customer

% of Total Company Volume

Danella Routing

Please help us get your registration information to the right team

Please select the Danella company or companies to receive your registration(Required)

Danella Contact(Required)

First Name Last Name

Danella Contact – Email(Required)

Certification

I hereby certify that the information provided in this document is true and accurate, to the best of my knowledge, and that I am an authorized representative of the Subcontractor (i.e. an employee or agent who is authorized to make representations for and enter into agreements that are binding on the Subcontractor):

Authorized Representative(Required)

First Name Last Name

Authorized Representative Title(Required)

Authorized Representative Phone(Required)

Authorized Representative Email(Required)

Date Completed(Required)

CAPTCHA

New Subcontractor Registration

Company Information

Subcontractor Representations

Subcontractor Representations (Continued)

Financial History

Insurance Information

Safety Information

Operations Information and References

References and Customer History

Danella Routing

Certification

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