1. COMPANY INFORMATION

• Company Name:
  (Complete attached W-9 Form)
• Contact:
• Federal Tax ID:
  (Required)
• Email:
• Physical Address:
• Web Address:
• Phone:
• Fax:
• City/State/Zip:
• License No.
• Mailing Address:
  (if different)

2. COMPANY HISTORY

• a. What year was your company founded? Years in business?
• b. Under what other or former name(s) has your company operated? (if none, please write "none")
  
• c. If your company is a corporation or partnership, please answer the following:
  (1). Date of Incorporation or Formation:
  (2). State of Incorporation or Formation:
  (3). President, Managing Partner or Manager’s Name:

3. LICENSE, UNION AND EXPERIENCE INFORMATION

• a. List the jurisdiction(s) and trade categories in which your company is legally qualified to do business, and indicate registration or license number(s), if applicable.
  
• b. If your company holds any local, state or federal certification as a Minority or Disadvantaged Business Enterprise (for example MWDBE, MBE, WBE, HUB), please identify which classification and provide a copy of the certification(s).
  
• c. Has your company ever failed to complete any work awarded to it? If so, please explain.
  
• d. List the major projects your company has completed in the past three (3) years. Provide the name of the project owner, architect, general contractor, contract amount, completion date and percentage of the work performed with your own workers.
  
• f. List the major projects your company has in progress. Provide the name of the project, owner, architect, general contractor, contract amount, percent complete and scheduled completion date.
  
• g. State your average yearly volume of work for the last three (3) years:
  20: $
  20: $
  20: $

4. TRADE REFERENCES (CURRENT MAJOR DEALERS AND SUPPLIERS)

• Name:
  Contact:
  Phone:
• Name:
  Contact:
  Phone:
• Name:
  Contact:
  Phone:
• Name:
  Contact:
  Phone:
• Name:
  Contact:
  Phone:
• Name:
  Contact:
  Phone:

5. FINANCIAL, SURETY AND CLAIM INFORMATION

• a. List surety company:
  Name:
  Address:
  Phone:
  Fax:
• b. List surety agent:
  Name:
  Address:
  Phone:
  Fax:
• c. Provide your bonding capacity:
  Single Project:
  Aggregate:
• d. Attach your company's financial statements for the last two (2) years, preferably audited. The financial statements must include your company's balance sheet and income statement and current statement should not be older than six (6) months from the date of this Pre-Qualification Statement.
  
• e. Are there any uninsured judgments, claims, arbitration proceedings or lawsuits currently pending against your company or its officers? If yes, please explain.
  
• f. Has your company filed any lawsuits or requested arbitration with regard to construction project within the last two (2) years? If yes, please provide:
  (1). Date and place filed:
  (2). Amount of lawsuit:
  (3). Disposition of claim:
• g. Provide the name of your Bank servicing your business:
  Bank Name:
  Address:
  Contact:
  Phone:
• h. Do you have any loan(s) outstanding? If yes, describe with due dates.
  
• i. Do you have a line of credit with your Bank? If yes, how much is your credit line?
  
• j. Have you co-signed any notes or provided guarantees on any debts outside of your business?
  

6. INSURANCE AND SAFETY INFORMATION

• a. Attach a current insurance certificate confirming coverage and policy amounts for the
  following:
  (1). Workers compensation (W/C)
  (2). Commercial General Liability (CG/L)
  (3). Automobile liability (A/L)
  (4). Excess (Umbrella) Liability (Ex/L)
  (5). Professional Liability
  
• b. Provide evidence, either on an insurance certificate or in a letter from your insurance agent, that
  your company’s insurance policies contain the following requirements or endorsements.
  Galaxy’s insurance template is attached for your use.
  (1). Waiver of Subrogation on W/C, CG/L, A/L, Ex/L
  (2). Additional Insured on CG/L, A/L, Ex/L (form CG 20101185 or an equivalent)
  (3). Primary and Non-Contributory on CG/L, Ex/L
  (4). Completed Operations for Additional Insureds
  (5). General Aggregate per Project/Job on CG/L
  
• c. Does your current General Liability policy exclude residential/habitational coverage?
  YesNo
• d. Does your current General Liability policy exclude coverage for EIFS?
  YesNo
• e. Does your company use leased workers to perform any part of your work?
  YesNo
  If Yes: Name of Leasing Company:
  Leasing Company's State License No.
• f. Furnish Worker's Compensation Risk I.D. No.
• g. Provide your company's Worker's Compensation Experience Modifiers for the last two (2) years:
  20 (current year)
  20 (prior year)
  If your Worker's Compensation Experience Modifier equals or exceeds 1.18, please provide a letter from your insurance company that specifically explains the factors that contributed to this rate.

• h. Has your company rejected Workers Compensation coverage in the State of Texas?
  YesNo

7. AUTHORIZED SIGNATURE

The undersigned certifies that the information provided in this Subcontractor Pre-Qualification
Statement is true and sufficiently completed so as not to be misleading and that the undersigned
is a duly authorized representative of Subcontractor.

• Dated this day of , 20.
• Name of Company:
• By:
• Printed Name:
• Title:
• Date: