PREQUAL FORM – WakeMed – SubVerify

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Welcome to the WakeMed Prequalification System, powered by SubVerify

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Service*
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SubVerified?
SubVerify is a service of Big Blue Innovations LLC. SubVerify is a process to verify core vendor prequalification data.
Project Name or ID
Click Here to see the list of information needed to complete this form.

The SubVerify prequalification application will ask you to submit detailed information about your company. After you submit your prequalification application we will immediately begin processing your record.

Our system is SSL encrypted and hosted over https architecture.

If you have any additional questions about our service or the process, please contact us at:

Big Blue Innovations dba SubVerify

SubVerify@bigblueinnovations.com

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GENERAL COMPANY INFORMATION
Legal Company Name*
Parent Company, Subsidiaries, Company Aliases, Previous Company Names
Company Website
Corporate Structure*
Name of President/CEO*
First Last
Company Information (Overview, Awards, Differentiators, etc.)
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Date the company was formed (per Secretary of State Filings) (sv)
Month
Day
Year
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Address on record with Secretary of State (sv)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does the company have a mailing address that is different than the physical address?*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Phone*

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Type of Shop*
Total Number of Paid Employees*
CSI Division (Trade)*
- N/A
- 1 - General
- 2- Site Construction
- 2 - Demolition
- 3 - Concrete
- 3 - Asphalt
- 4 - Masonry
- 5 - Metals
- 6 - Wood and Plastics
- 7 - Thermal and Moisture Protection
- 7 - Fire Stopping
- 8 - Doors and Windows
- 9 - Finishes (Wall Coating/Covering)
- 9 - Finishes (Flooring)
- 9 - Finishes (Metal Framing/Drywall/ACT)
- 10 - Specialties
- 11 - Equipment
- 12 - Furnishings
- 13 - Special Construction
- 14 - Conveying Systems
- 15 - Mechanical/Plumbing
- 15 - Medical Gas
- 15 - Fire Protection/Sprinkler
- 16 - Electrical
- 16 - Low Voltage
- 16 - Fire Alarm
Detailed Trade Info*
Select all CSI subdivisions trades that apply. For GC's, select those trades that you may self-perform.
Professional Licenses
Sector Experience*
Select all that apply
States Served*
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
- Armed Forces Americas
- Armed Forces Europe
- Armed Forces Pacific
Select the states which the company provides goods or services.

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COMPANY POINT OF CONTACT
Company Point of Contact Name*
First Last
Company Point of Contact Phone*
Company Point of Contact Email*
PRECONSTRUCTION / ESTIMATING POINT OF CONTACT
Preconstruction/Estimating Name*
First Last
Preconstruction/Estimating Phone*
Preconstruction/Estimating Fax
Preconstruction/Estimating Email*
COMPANY TAX INFORMATION
Federal Identification Number*
Also known as the Employer Identification Number
W-9 Upload*
Drop files here or

Max. file size: 512 MB, Max. files: 3.
HUB / MINORITY PARTICIPATION INFORMATION
Is the company classified as a Minority Business Enterprise or Historically Underutilized Business or other classification?*
Business Classification*
- Minority Business Enterprise (MBE)
- Disabled Veteran Business Enterprise (DVBE)
- HUBZone Business
- Small Disadvantaged Business Enterprise (SDB/DBE)
- Woman Business Enterprise (WBE)
- Other
Select all that apply

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BONDING INFORMATION
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Bonding Information Disclaimer
- SubVerify was unable to obtain a response from the Agent/Carrier to verify this information.
Can the company secure a bond?*
Bonding Company*
Bonding Company Contact*
First Last
Bonding Company Contact Phone*
Bonding Company Contact Email*
Bond Underwriter*
If same as bonding company, please enter it again here.
Single Project Bond Capacity*
Aggregate Bond Capacity*
Current Available Bond Capacity*
Letter of Good Standing from Bonding Company
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Max. file size: 512 MB.
Optional
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Number of Years with Current Bonding Company (available when subverified)
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Has Bonding Company ever paid a bond claim on this company? (available when subverified)
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A.M. Best Rating (extract from ambest.com) (available when subverified):
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Max. file size: 512 MB.

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INSURANCE INFORMATION
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Insurance Information Disclaimer
- SubVerify was unable to obtain a response from the Agent/Carrier to verify this information
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Does the company have insurance coverage
Upload your Certificate of Insurance or Memorandum of Insurance
Max. file size: 512 MB.

Have your agent or carrier make the COI out for WakeMed Health & Hospitals as proof of coverage.
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Name of Producer (Insurance Company)*
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Insurance Company Contact*
First Last
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Insurance Company Contact Phone*
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Insurance Company Contact Email*
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Insurance Policy Number*
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Insurer Affording General Liability Coverage
Enter the name of the provider. If you do not have this coverage, enter "none". This block is not asking for the coverage amount.
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General Liability - Limit per Occurrence
If this coverage does not apply, enter 0.
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General Liability - Aggregate Limit
If this coverage does not apply, enter 0.
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General Liability - Personal & Adv Injury
If this coverage does not apply, enter 0.
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General Liability - Medical Expense (any 1 person)
If this coverage does not apply, enter 0.
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General Liability - Fire Damage
If this coverage does not apply, enter 0.
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General Liability - Rented Property
If this coverage does not apply, enter 0.
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Insurer Affording Automobile Liability Coverage
Enter the name of the provider. If you do not have this coverage, enter "none". This block is not asking for the coverage amount.
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Automobile - Combined Single Limit
If this coverage does not apply, enter 0.
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Automobile - Bodily Injury (per person)
If this coverage does not apply, enter 0.
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Automobile - Bodily Injury (per accident)
If this coverage does not apply, enter 0.
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Automobile - Property Damage
If this coverage does not apply, enter 0.
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Insurer Affording Umbrella/Excess Liability Coverage
Enter the name of the provider. If you do not have this coverage, enter "none". This block is not asking for the coverage amount.
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Umbrella / Excess Liability - Each Occurrence
If this coverage does not apply, enter 0.
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Umbrella / Excess Liability - Aggregate
If this coverage does not apply, enter 0.
Insurer Affording Workers Comp/Employer Liability Coverage
Enter the name of the provider. If you do not have this coverage, enter "none". This block is not asking for the coverage amount.
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Workers Comp / Employer Liability - Each Accident
If this coverage does not apply, enter 0.
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Workers Comp / Employer Liability - Disease Each Employee
If this coverage does not apply, enter 0.
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Workers Comp / Employer Liability - Disease Policy Limit
If this coverage does not apply, enter 0.
Other Endorsements / Special Items / Descriptions
If this is not applicable, type "none."

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FINANCIAL INFORMATION
DUNS Number
Does the company have a history of bankruptcy?*
Please state year(s) in which company entered bankruptcy, the current status of the company and any other comments that the company would like to provide.*
Upload current Work In Progress (WIP) report, also called Work on Hand
Drop files here or

Max. file size: 512 MB.
If you do not have this type of report, upload a document stating that you do not generate these reports.
Financial Institution of Company*
Financial Institution Contact Name*
First Last
Financial Institution Contact Phone*
Financial Institution Contact Email*
Letter of Good Standing from Financial Institution
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Max. file size: 512 MB.
Optional
Financial Statements*
- Acknowledgement
In order to properly prequalify the company we ask that you share your company's financial statements in this application. The information is protected under strict confidentiality and per the Privacy Policy and the User Agreement. The minimum information that is asked for is the company's year-end balance sheet. It is understood that the income statement contains sensitive information, therefore that document is not required. Acceptable Financial Statements Include: For Sole Proprietorship - IRS Schedule C, Year End Balance Sheet For LLC's & Corporations - Full Financial statements are preferred but end of year balance sheets will suffice. You may contact Jake Williamson at WakeMed for any questions related to submission of financial statements. His email address is jawilliamson@wakemed.org
Current Financial Statements*
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Max. file size: 512 MB.
2nd Most Current Financial Statements*
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Max. file size: 512 MB.
3rd Most Current Financial Statements*
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Max. file size: 512 MB.

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SAFETY INFORMATION
Current Experience Modifier Rating*
If you do not know your EMR, please contact your insurance carrier or the Department of Labor for assistance.
2nd Most Current Experience Modifier Rating*
If you do not know your EMR, please contact your insurance carrier or the Department of Labor for assistance.
3rd Most Current Experience Modifier Rating*
If you do not know your EMR, please contact your insurance carrier or the Department of Labor for assistance.
Do you have a written safety program/policy?*
Upload your safety program/policy*
Max. file size: 512 MB.
Do you have a written substance abuse policy?*
Upload your substance abuse policy*
Max. file size: 512 MB.
OSHA Recordable Incident Rate (also known as Total Recordable Incident Rate
Visit the following site for guidance on how to calculate this rate if the Bureau of Labor Statistics or Department of Labor has not issued you one www.data.bls.gov/iirc/data_tool=IIRC
Past 3 years of OSHA 300 Logs
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Max. file size: 512 MB.
You indicated that the company has more than 10 employees. Per OSHA, you are required to maintain OSHA records and 300 logs. Please upload them here. For more information go to https://www.osha.gov/recordkeeping/
Has the company had any OSHA citations in the last 3 years?*
LEGAL INFORMATION
Does the company verify employment eligibility and legal work status through e-Verify or an equivalent system or process?*
Doe the company have policies and procedures to appropriately assign employees to projects?*
For example, a procedure that ensures employees with criminal history are not assigned to certain projects that may place them or the company in violation of law or client policy.
To the best of your knowledge, does the company have any employees that are convicted sex offenders?*
To the best of your knowledge, does the company have employees that have been convicted of any other felony?*
Has the company been engaged in any legal actions in the last 10 years?*
Legal action includes mediation, arbitration, litigation or court settlements.
Select all of the legal activities which the company has been named in during the last 10 years.*
- Mediation
- Arbitration
- Litigation/Lawsuit
- Court Settlement
- N/A
Is the company involved in any active liens?*
Please provide a document further explaining the circumstances (to the extent possible) of any legal activity that you indicated the company has been involved in.
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Max. file size: 512 MB.

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CONTRACT PERFORMANCE
Average Contract Value*
Largest Single Contract Value Completed To Date*
Has the company ever failed to complete a project for reasons other than acts of god?*
Please explain the circumstance (to the extent allowed) of projects that the company failed to complete.*
Contract & Project Delivery Experience (Select all that apply)*
- CM-At-Risk
- Design-Build
- Guaranteed Maximum Price
- Integrated Project Delivery
- Lump Sum
- Multi-Prime
- N/A
Does the company practice any of the following? (Select all that apply)*
- Building Information Modeling / Virtual Design & Construction
- Lean Construction
- LEED / Sustainable Construction
- N/A
HEALTHCARE SECTOR PERFORMANCE
Experience working on the following patient care or support facilities (Select all that apply)*
- Administrative Building (Business Offices)
- Childcare Facility
- Energy Plant
- Hospital
- Medical Office Building (clinics, urgent care, etc.)
- Mental Health Facility
- Nursing Facility (Hospice, Long-term care, Assisted Living, etc.)
- Free Standing Pharmaceutical or Lab
- Substance Rehabilitation Facility
- Surgery Center
- Wellness Center
- N/A
Experience working on the following clinical environments (Select all that apply)*
- Airborne Isolation Units
- Behavioral/Mental Health
- Bronchoscopy Suite
- Cardiovascular Thoracic/Open Heart Unit
- Cath or EP Laboratory
- Child Day Care
- Critical/Intensive Care Unit (CCU or ICU)
- Data Records
- Decontamination Units
- Dialysis Suite
- Food & Nutrition/Cafeteria/Kitchen
- Gastroenterology Laboratory (GI Lab)
- Imaging - CT / PET Scan
- Imaging - General Radiology/X-Ray
- Imaging - MRI
- Imaging - Ultrasound/Mammography
- Inpatient Rehabilitation (i.e. Stroke Rehab)
- IT Data Center
- Laboratory (Lab)
- Labor & Delivery / Women & Children
- Medical Surgical/Step-Down Units
- NeoNatal Intensive Care Unit (NICU)
- Operating Room/Surgical Suites
- Post Anesthesia Care Unit (PACU)
- Pediatrics Unit
- Pharmacy
- Radiation Oncology - Linear Accelerator
- Radiation Oncology - Other
- Sterile Processing
- Transplant Unite
- N/A

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QUALIFICATIONS & CREDENTIALS
Have employees attended the NFPA 101 Life Safety Code course?*
For more information about this training program visit: http://www.nfpa.orf/catalog/category.asp?category_name=Training&filter_type=Seminar&cookie_test=1
Have employees attended the ASHE Health Care Construction SUBCONTRACTOR PROGRAM?*
For more information about this training program visit: http://www.ashe.org/learn/e-learning_programs/subcontractor/
Have employees attended the ASHE Health Care Construction Certification: Certificate Workshop?*
For more information about this training program visit: http://www.ashe.org/learn/seminars_and_workshops/
Have employees attended the ASHE Health Care Facility Management - Managing the PDC Process course?*
For more information about this training program visit: http://www.ashe.org/learn/seminars_and_workshops/
Have employees attended the ASHE Health Care Management and Construction - Infection Prevention course?*
For more information about this training program visit: http://www.ashe.org/learn/seminars_and_workshops/
Does the company have USGBC LEED Accredited Professionals on staff?*
For more information about this program visit: http://www.usgbc.org/credentials
Does the company have staff that hold the American Hospital Association Certified Healthcare Constructor or Healthcare Facility Manager certification?
For more information about this program visit: http://www.aha.org/certifcenter/CHC/index.shtml
Does the company have staff that hold the Project Management Institute PMP designation?*
For more information about this program visit: http://www.pmi.org/Certification/Project-Management-Professional-PMP.aspx

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PROJECT PORTFOLIO
Project #1
Project Name
Project Owner
Project Location
City State / Province / Region
Date Completed
Month
Day
Year
Contract Amount
Project Description
Project #1 Photos, Drawings, etc.
Drop files here or

Max. file size: 512 MB.
This is optional
Check all that applied to this project
- Use of BIM / 3D modeling
- Lean processes
- LEED certified projet
- Privately funded
- Public/Government funded
- Integrated Project Delivery
- CM-At-Risk
- Design-Build
- Guaranteed Maximum Price
- Lump Sum
- Multi-Prime
- Renovation
- New Construction
Project #2
Project Name
Project Owner
Project Location
City State / Province / Region
Date Completed
Month
Day
Year
Contract Amount
Project Description
Project #2 Photos, Drawings, etc.
Max. file size: 512 MB.

This is optional
Check all that applied to this project
- Use of BIM / 3D modeling
- Lean processes
- LEED certified projet
- Privately funded
- Public/Government funded
- Integrated Project Delivery
- CM-At-Risk
- Design-Build
- Guaranteed Maximum Price
- Lump Sum
- Multi-Prime
- Renovation
- New Construction
Project #3
Project Name
Project Owner
Project Location
City State / Province / Region
Date Completed
Month
Day
Year
Contract Amount
Project Description
Project #3 Photos, Drawings, etc.
Max. file size: 512 MB.

This is optional
Check all that applied to this project
- Use of BIM / 3D modeling
- Lean processes
- LEED certified projet
- Privately funded
- Public/Government funded
- Integrated Project Delivery
- CM-At-Risk
- Design-Build
- Guaranteed Maximum Price
- Lump Sum
- Multi-Prime
- Renovation
- New Construction

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REFERENCES
Reference #1
Reference #1 Opt Out
- I am opting out of providing this reference.
Select Opt Out if you do not have a reference to provide.
Reference is a (Select one)*
Company Name*
Ref #1 Contact Name*
First Last
Ref #1 Contact Phone
Ref #1 Contact Email
Ref #1 Project Name/Description*
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Ref #1 Provided Positive Feedback on (available when subverified):
- Compliance with specs
- On/Ahead of schedule
- Responsive to issues
- Planning & Sequencing work
- Coordination among project team
- Safety
- Would work with them again
- No positive feedback
- Reference not available
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Reference #1 Unresponsive (when subverified only):
- Reference #1 Unresponsive
Reference #2
Reference #2 Opt Out
- I am opting out of providing this reference.
Select Opt Out if you do not have a reference to provide.
Reference #2 is a (Select one)*
Ref #2 Company Name*
Ref #2 Contact Name*
First Last
Ref #2 Contact Phone*
Ref #2 Contact Email*
Ref #2 Project Name/Description*
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Ref #2 Provided Positive Feedback on (available when subverified):
- Compliance with specs
- On/Ahead of schedule
- Responsive to issues
- Planning & Sequencing work
- Coordination among project team
- Safety
- Would work with them again
- No positive feedback
- Reference not available
This field is hidden when viewing the form
Reference #2 Unresponsive (when subverified only):
- Reference #2 Unresponsive
Reference #3
Reference #3 Opt Out
- I am opting out of providing this reference.
Select Opt Out if you do not have a reference to provide.
Reference #3 is a (Select one)*
Ref #3 Company Name*
Ref #3 Contact Name*
First Last
Ref #3 Contact Phone*
Ref #3 Contact Email*
Ref #3 Project Name/Description*
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Ref #3 Provided Positive Feedback on (available when subverified):
- Compliance with specs
- On/Ahead of schedule
- Responsive to issues
- Planning & Sequencing work
- Coordination among project team
- Safety
- Would work with them again
- No positive feedback
- Reference not available
This field is hidden when viewing the form
Reference #3 Unresponsive (when subverified only):
- Reference #3 Unresponsive
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Positive Reference Ratio (0.75 = 75%) (available when subverified)
For example, 0.75 = 75% or half of references indicated they would work with them again.

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