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College of the Siskiyous Insurance Requirements (College of the Siskiyous)

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College of the Siskiyous Insurance Requirements
Minimum Insurance Coverage for 2019/20 Pre-Qualification
Contractor Insurance. The Contractor shall obtain and maintain the following insurance
coverages with minimum coverage amounts as set forth below:
Policy of Insurance
Minimum Coverage Amount
Commercial General Liability Insurance
Per Occurrence: $1,000,000
Aggregate: $2,000,000
Auto Liability
$500,000
Workers Compensation
In accordance with the laws
Employers Liability
$1,000,000
Builders Risk
Full insurable value of the Work;
Seismic coverage:
Not Required
Required
Specified per Job
When requested (per job):
The following sentence shall be included in the additional insured endorsements:
“Siskiyou Joint Community College District, its Governing Board, as individuals and as an
entity, its officers, directors, employees, agents, and volunteers, are hereby named as
additional insured, with respect to all work performed by or on behalf of the named insured
under its contract with the Certificate Holder.”
COLLEGE OF THE SISKIYOUS
SISKIYOU JOINT COMMUNITY COLLEGE
DISTRICT
UNIFORM CONSTRUCTION COST ACCOUNTING; INFORMAL
BIDDING
PRE-
QUALIFICATION
APPLICATION
(Public Contract Code §22030 et seq.
for
Projects Valued Between $45,000 and
$175,000)
FOR THE 2020 CALENDAR
YEAR
Return Application
to:
By
Mail:
College of the Siskiyous
Attn: Melinda Garland
800 College Avenue
Weed, CA 96094
Or by
Email: mgarland@siskiyous.edu
Phone: (530) 938-5233
PRE-QUALIFICATION APPLICATION: INFORMAL BIDDING
UNIFORM PUBLIC CONSTRUCTION COST ACCOUNTING
(Public Contract Code §22030 et seq. for Projects Valued Between $45,000 and $175,000)
FOR THE 2020 CALENDAR YEAR
The undersigned applicant requests that Siskiyou Joint Community College District (District)
pre-qualify the applicant to bid on the District’s informally bid projects, as authorized by Public
Contract Code §22030, et seq.
1. Applicant Information. Complete the following to provide information about the applicant.
Firm/Company Name:
Physical Office Location
Street Address:
City: State: Zip:
Mailing Address (if different from physical office location)
Street Address:
City: State: Zip:
Applicant Contacts
Name:
Phone: Email:
Name:
Phone: Email:
Applicant California Contractors’ License
License #: Expiration Date:
Classifications:
Applicant DIR Registration
Registration #: Expiration Date:
2. Pre-Qualification. The applicant requests to be pre-qualified for submitting proposals for
the District’s informally bid projects in the classification(s) noted by the application in Exhibit
A (Pre-Qualification Classifications) attached to this application.
3. Applicant Annual Revenue. Complete the following. If the applicant is engaged in business
enterprises other than construction, responses to the following are limited to the applicant’s
construction operations.
Calendar Year/
Fiscal Year
Annual Gross
Revenue
Average Dollar
Value of All
Contracts
2018 (FY 2017/2018)
2017 (FY 2016/2017)
2016 (FY 2015/2016)
4. Applicant Insurance and Bonding. Complete the following for the applicant’s current
General Liability Insurance, Workers Compensation insurance and bonding capacity.
General Liability Insurance
Insurer: Policy No:
Per Occurrence Coverage Limit $ Aggregate Coverage Limit $
Broker:
Contact Name:
Street Address:
City: State: Zip:
Phone: Fax:
Email:
4. Applicant Insurance and Bonding (cont.) Complete the following for the applicant’s
current General Liability Insurance, Workers Compensation insurance and bonding capacity.
Bid, Performance, and Labor and Materials Payment Bonds
Surety:
Max per Project Bonding Capacity $ Max All Projects Boding Capacity $
Surety Broker:
Contact Name:
Street Address:
City: State: Zip:
Phone: Fax:
Email:
Workers Compensation Insurance
Insurer: Policy No:
Broker:
Contact Name:
Street Address:
City: State: Zip:
Phone: Fax:
Email:
5. Current Public Works Projects. Complete the following to identify all public works
construction projects for which the applicant is under contract as of the date of submitting
this application. Duplicate this page as necessary to identify all of the applicant’s current
public works projects.
Project Description
Owner and Owner Contact Information
Name:
Contact Person:
Phone: Email:
Architect and Architect Contact Information
Name:
Contact Person:
Phone: Email:
Contract Information
Applicant Contract Value $
Applicant Scope of Work:
Percent Complete; Applicant Work: Percent Complete; Overall Project:
6. Prior Public Works Projects. Complete the following to identify all public works
construction projects for which the applicant completed in the three (3) years preceding the
date of submitting this application. Duplicate this page as necessary to identify all of the
applicant’s public works projects completed in the preceding three (3) years.
Project Description
Owner and Owner Contact Information
Name:
Contact Person:
Phone: Email:
Architect and Architect Contact Information
Name:
Contact Person:
Phone: Email:
Contract Information
Applicant Contract Value $
Applicant Scope of Work:
Percent Complete; Applicant Work: Percent Complete; Overall Project:
7. References. Complete the following to identify applicant references.
DSA Inspectors References
Firm Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Firm Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Firm Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
7. References (cont.) Complete the following to identify applicant references.
Material Supplier References
Supplier Name:
Supplier Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Supplier Name:
Supplier Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Supplier Name:
Supplier Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
7. References (cont.) Complete the following to identify applicant references.
Public Agency Owners (California K-12 or Community College Owners Preferred)
Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
7. References (cont.) Complete the following to identify applicant references.
Architect References
Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
Name:
Contact Person:
Street Address:
City: State: Zip:
Phone: Email:
8. Essential Questions. An applicant will not be pre-qualified if the response to any of the
following essential questions results in a “Not Qualified” designation.
8.1 The applicant possesses a valid and currently in good standing California Contractors’
license for the trade category(ies) for which the applicant requests pre-qualification.
Yes No (Not qualified)
8.2 The applicant is a DIR registered contractor.
Yes No (Not qualified)
8.3 Applicant maintains a commercial general liability insurance policy with a coverage
amount of at least $1,000,000 per occurrence and $2,000,000 in the aggregate.
Yes No (Not qualified)
8.4 Applicant has a current workers’ compensation insurance policy as required by the
Labor Code or is legally self-insured pursuant to Labor Code §3700.
Yes No (Not qualified)
8.5 Applicant has bonding capacity of at least Two Hundred Thousand Dollars ($200,000)
per project and One Million Dollars ($1,000,000) in the aggregate for all projects.
Yes No (Not qualified)
8.6 Within the past twenty-four (24) months, has the applicant provided public works
construction services under a direct contract with a public owner where the value of
the construction services provided by the applicant was greater than $50,000?
Yes No (Not qualified)
8.7 The applicant is ineligible or debarred from submitting bid proposals for public works
projects or public works contracts pursuant Labor Code §1777.1 or Labor Code
§1777.7.
Yes No (Not qualified)
8.8 Within the past five (5) years, has a public agency determined that the applicant or any
predecessor to the applicant, is not a “responsible” bidder for a public works project or
a public works contract?
Yes No (Not qualified)
8.9 During the past five (5) years, has the applicant or any predecessor to the applicant, or
any of the equity owners of the applicant been convicted of a federal or state crime
involving fraud, theft, or any other act of dishonesty?
Yes No (Not qualified)
8.10 During the past five (5) years a surety has completed any project or the applicant’s
obligations under a construction contract.
Yes No (Not qualified)
8.11 During the past five (5) years the applicant has been declared in default under a
construction contract to which the applicant was a party.
Yes No (Not qualified)
8.12 The applicant’s Worker’s Compensation Insurance prior five (5) year average
Experience Modification Rating (EMR) rating is more than 1.5.
Yes No (Not qualified)
8.13 The applicant’s Worker’s Compensation Insurance current average Experience
Modification Rating (EMR) rating is more than 1.5.
Yes No (Not qualified)
8.14 CAL OSHA or OSHA has cited and assessed penalties against the Applicant for
“serious,” “willful” or “repeat” violations of its safety or health regulations in the past
give (5) years.
Yes No (Not qualified)
9. Asbestos Work; Hazardous Substance Removal Certifications. Each applicant must
respond to Questions 9.1 and 9.2 even if the applicant does not request pre-qualification for
asbestos work or hazardous material substance removal work.
9.1 The bidder possesses a current and in good standing ASB-Asbestos Certification
issued by the California Contractor’s License Board.
Yes No (Not qualified for asbestos-related work)
9.2 The bidder possesses a current and in good standing HAZ-Hazardous Substance
Removal Certification issued by the California Contractors’ State License Board.
Yes No (Not qualified for hazardous substance removal)
10. Authority and Certification. The undersigned is duly authorized to execute this pre-
Qualification Application under penalty of perjury on behalf of the above-identified applicant.
The undersigned warrants and represents that he/she has personal knowledge of each of
the responses to this Pre-Qualification Application and/or that he/she has conducted all
necessary and appropriate inquiries to determine the truth, completeness and accuracy of
responses to this Pre-Qualification Application. The undersigned declares and certifies that
the responses to this Pre-Qualification Application are complete and accurate; there are no
omissions of material fact or information that render any response to be false or misleading
and there are no misstatements of fact in any of the responses. The applicant
acknowledges and agrees that if the District determines that nay response herein is false or
misleading or contains misstatements of fact, the applicant will not be deemed qualified to
participate in the District’s informal bidding procedures.
Executed this day of , 20 at (city, state)
I declare under penalty of perjury under California law that the foregoing is true and correct.
(Printed Name) (Title)
(Signature) (Date)
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College of the Siskiyous Insurance Requirements (College of the Siskiyous)

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Completed 25 July 2020

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