Become a Trehel Corp. Subcontractor

Company Name*

Is Company a DBA?

If Company is a DBA, Owner Name

Name Last

Company President/CEO Name

Name Last

President/CEO Email

Contact Person for Insurance Requests*

First Last

Email

Phone

Please enter a direct number if different from general company phone number.

Extension (if applicable)

Contact Person for Accounts Receivable*

First Last

Email

Phone

Please enter a direct number if different from general company phone number.

Extension (if applicable)

Contact Person for Estimating*

First Last

Email

Phone

Please enter a direct number if different from general company phone number.

Extension (if applicable)

Phone*

Fax No.

Mailing Preference*

Physical Address*

Street Address City State ZIP Code

PO Box (if applicable)

PO Box City State ZIP Code

Federal Tax ID/ SS Number*

Form 1099 Required?*

Entity Type*

If DBA, do you require the owner’s name on the check?

Please Provide Trade License #’s, Limits and Expiration Dates

Please Attach a Copy of Your W-9 Form*

Please Attach Current Business License

If company holds multiple licenses, please attach the license that includes your headquarter's location.

Year the Business was Founded*

Number of Employees*

Specific Services Provided*

Licensed to Work In*

SC
NC
GA

(check all that apply)

What additional states are you authorized to perform work?

Maximum Travel Distance

What portions of work are self-performed & subcontracted?*

Insurance

Insurance Agency*

Insurance Agent Name

First Last

Phone*

Email

Is the Company Insured?*

Please read the following minimum limits requirement, before selecting your answer below. You may view our sample certificate of liability insurance by clicking here.

General Liability

Certificate holder and owner are listed as Additional Insured, including completed operations (see sample certificate for endorsement number)
A Waiver of Subrogation in favor of the certificate holder and owner
The following minimum limits:
o Each Occurrence: $1,000,000
o General Aggregate: $2,000,000
o Products – Comp/OP AGG: $2,000,000
Insurance listed is primary and non-contributory

Auto

A Waiver of Subrogation in favor of the certificate holder and owner
Every vehicle that enters the jobsite must be insured
The following minimum limits:
o Combined Single Limit (Ea accident): $1,000,000

Workers Comp

A Waiver of Subrogation in favor of the certificate holder and owner
If an executive officer is excluded, an affidavit must be submitted stating that the excluded officer will not be present on the job site.
The following minimum limits:
o $500,000/$500,000/$500,000

General Liability*

Auto*

Worker's Comp*

Umbrella*

Please Attach Current Insurance Certificate(s)*

Drop files here or

This Business Qualifies As A (check all that apply):

Large Business (a major corporation with more than 500 employees)
Women-Owned Small Business (a business at least 51% of which is owned by one or more women who are found to be disadvantaged and whose management and daily operations are controlled by such individuals)
Veteran-Owned Small Business (a business at least 51% of which is owned by one or more Veterans and whose management and daily operations are controlled by such individuals)
Service-Disabled Veteran-Owned Small Business (a business at least 51% of which is owned by one or more Veterans who have a service-connected disability that has been determined by the Department of Veterans Affairs or Department of Defense and whose management and daily operations are controlled by such individuals)
Minority-Owned Small Business (a business at least 51% of which is owned by one or more minority individuals or other individuals found to be disadvantaged and whose management and daily operations are controlled by such individuals)

If Minority-Owned Small Business, which minority?

If Minority-Owned Small Business, what gender is the owner?

Has your company received their certification?

Do you have experience with LEED/green buildings?*

You do NOT have to be LEED certified to answer yes.

Safety Officer's Name*

Or professional in charge of your safety program.

Title*

Phone*

Extension (if applicable)

What is your workers comp EMR (experience modification rate) for the past three (3) years?

Year*

EMR*

Year*

EMR*

Year*

EMR*

Is Your Company Bonded?*

Surety Company

Surety Agent

Phone

Email

Bonding Limit Per Project

Bond Rate

If tiered, please list contract amounts and rates.

Provide Three (3) Client References

Please list three clients who you have recently worked with and can attest to your expertise.

Company*

Contact Name*

Phone*

Email

Company*

Contact Name*

Phone*

Email

Company*

Contact Name*

Phone*

Email

Any Additional Information We Should Know?

I hereby certify that all of the information provided above is true and accurate.

Applicant's Name*

First Last

Title*

Applicant's Email*

Date*

If you have any questions or concerns about the information requested, please contact us at 864-284-9439 or precon@trehel.com. Thank you for your cooperation.

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