U.S. Subcontractor Qualification – Irex Contracting Group

Contractor's Firm Name
Street Address
City
State
Zip Code
Contact Name
Telephone Number
Are you a WBE or MBE company?*
- Yes
- No
If yes, please provide your Certificate #
Has your company been federally or state debarred?*
- Yes
- No
For which Irex U.S. Subsidiary are you submitting this form?
Name of person at this Irex subsidiary company who asked you to complete this form:

Please provide the following information relative to your firm's safety performance and program:
Certificate of Liability Insurance AND Experience Modification Rate (EMR)

Please obtain from your insurance agent a Certificate of Liability Insurance showing the general liability, auto (if applicable) and workers compensation coverages. The certificate must list the above selected company's name as a certificate holder as well as an additional insured. Please attach the certificate to this form.
Insurance Requirements:
General Liability: $2,000,000
Automobile Liability: $1,000,000
Umbrella/Excess: $5,000,000 each occurrence
Workers Compensation: $1,000,000
Does your company meet the insurance requirements stated including limits and excess limits, waiver of subrogation, and additional insured status?
- Yes
- No
Sample Certificate of Insurance:
Click Here For Sample
Please obtain from your insurance agent (or state fund, if applicable) your interstate EMRs for the last three rating periods. If you do not have an interstate rating, obtain your intrastate EMRs. Then complete the following data:
Current policy year - Effective Dates
Current policy year - Modification Rate
One year previous - Effective Dates
One year previous - Modification Rate
Two years previous - Effective Dates
Two years previous - Modification Rate
Is your firm self-insured for Workers’ Compensation claims?
- Yes
- No
We require backup for the above information. Please furnish a letter from your insurance agent, insurance carrier, or state fund (on their letterhead) verifying the EMR data listed above.
How many years has your firm been in business under your present firm name?

OSHA Recordable Incidents
Furnish a copy of your firm’s OSHA Forms 300 and 300A from the past three (3) years. It is unlikely we can qualify your company to bid work without these forms.
Some firms are not required to complete the OSHA 300 Log because they have too few employees (less than ten at any time during the calendar year) or are exempted by virtue of the services they perform. If you don’t complete an OSHA 300 Log, is it because your firm:
Has too few employees?
- Yes
- No
Performs a service, which is exempted from completing an OSHA 300 Log?
- Yes
- No
If you do not complete an OSHA 300 Log and you answered “No” to the above questions, please explain.
The answers you provide in this section may determine whether you will be permitted to bid work. You are responsible and accountable for providing accurate information. Using your past three years OSHA Logs, provide the following injury and illness information. Provide the information whether or not you are required to keep a Log per OSHA recordkeeping guidelines:
Enter details for Year 1
Year*
Number of Fatalities*
Number of lost workday cases*
Total number of restricted cases*
Total number of recordable cases*
Total employee hours worked*
Number of employees*
Enter details for Year 2
Year*
Number of Fatalities*
Number of lost workday cases*
Total number of restricted cases*
Total number of recordable cases*
Total employee hours worked*
Number of employees*
Enter details for Year 3
Year*
Number of Fatalities*
Number of lost workday cases*
Total Number of restricted cases*
Total number of recordable cases*
Total employee hours worked*
Number of employees*
Have you had any regulatory agency inspections in the last three (3) years?
- Yes
- No
If you answered “Yes”, please provide copies of the documentation, including any citations issued.
Attach the following documents: 2MB MAXIMUM TOTAL FILE SIZE ACCEPTED
File 1: EMR Verification
File 2: OSHA Logs
File 3: Certificate of Insurance
File 4: W-9 Form
File 5: WBE or MBE Certificate (if applicable)
File 6: Other (if applicable)

Step 1 of 4

Sample Certificate of Insurance: