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10. In the past five years, has your firm made any claim against a project owner concerning work on a roject
<br />or payment for a contract, and filed that claim in court or arbitration? [I Yes No
<br />If "yes," on a separate page identify the claim(s) by providing the project name, date of the claim, name of
<br />the claimant, the name of the entity the claim was filed against, a brief description of the nature of the
<br />claim, the court and case number, and a brief description of the status of the claim (pending or, if
<br />resolved, a brief description of the resolution.)
<br />11. At any time during the past five years, has any surety company made any payments on your firm's behalf
<br />as a result of a default, to satisfy any claims made against a performance or payment bond issued on
<br />your firm's behalf in connection with a project, either public or private? ❑ Yes ® No
<br />12. In the last five years, has any insurance carrier, for any form of insurance, refused to renew he insurance
<br />policy policy for your firm?
<br />13. Has your firm or any of its owners, officers, or partners ever been liable in a civil suit, or found guilty in a
<br />criminal action, for making any false claim or material misrepresentation to any public agency or entity?
<br />❑ Yes ❑ No
<br />14. Has your firm or any of its owners, officers or partners ever been convicted of a federal or❑ state
<br />Yes crime ❑ No
<br />fraud, theft, or any other act of dishonesty?
<br />If "yes," identify on a separate page, the person or persons convicted, the court case and number, the
<br />crimes and the year convicted.
<br />15. If your firm was required to pay a premium of more than one percent for a performance and payment
<br />bond on any project(s) on which your firm worked at any time during the last three years, state the
<br />percentage that your firm was required to pay. You may provide an explanation for a percentage rate
<br />higher than one percent, if you wish to do so.
<br />16. During the last five years, has your firm ever been denied bond credit by a surety company, or has there
<br />ever been a period of time when your firm had no surety bond in place during a project w one was No
<br />required? El
<br />17. Has Cal -OSHA cited and assessed penalties against the contractor or its associates for any "serious,"
<br />"willful" or "repeat" violations of its safety or health regulations in the past five years? ❑ Yes ® No
<br />(Note: If you have filed an appeal of a citation, and the Occupational Safety and Health Appeals Board
<br />has not yet ruled on your appeal, you need not include information about it.)
<br />If "yes," on a separate page describe the citations, the party against whom the citation was made, date of
<br />citation, nature of the violation, project on which the citation was issued, owner of the project, and the
<br />amount of penalty paid, if any. State the case number and the date of any OSHAB decision.
<br />18. Has the Federal Occupational Safety and Health Administration cited and assessed penalties against the
<br />contractor or its associates in the past five years? ❑ Yes ® No
<br />(Note: If an appeal of the citation has been filed and the Appeals Board has not yet ruled, or there is a
<br />court appeal pending, you need not include information about the citation.)
<br />If "yes," on a separate page describe the citation, the party against whom the citation was made, date of
<br />citation, nature of the violation, project on which the citation was issued, owner of project, and the amount
<br />of penalty paid, if any. State the case number and date of any decision.
<br />FUM
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