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'ICE, to the past We years, has your firm made any claim against a project owner concerning work on a
<br />project or payment for a contract, and filoct that clatfrn in court or arbitration? [] Yes JE No
<br />if 'yes.- on a separate page identify the ctairrttsj by providing the project name, date Of the claim,
<br />I ame of the claimant, the name of the entity the claim was filed against, a brief description of file
<br />nature of Ure claim, the court and case rivinber, and a brief descaptlon of the status of the claim
<br />(pending, or if resolved, a brief description of the resolution.)
<br />11, At any flare during the peal five years, has any surety company made any payments on your firm's
<br />behalf as a result of a default, to satisfy any claims made against a performance or payment bond
<br />issued on your firm's behalf to connection with a project, either public or Prlva10 ❑ Yes X No
<br />1 . In the last five years. his any insurance carrier, for any form of insurance, refuied to reneuW can
<br />insurance policy for your firm'* [ Yes 0 No
<br />13. Has your firm or any of its ovvillers, ctficers, or partners aver been liable in a Civil suit, or found guilty
<br />In a criminal action, for making any false claim or materiaf misrepresenallon to arr,y pabf'sc agency
<br />or entity? C) Yee 0 No
<br />14. Has your firm or any of its owners, Officers or partnersever been convicted of a federal! or state
<br />crime of fraud, theft, or any other act of dishonesty? []Yes ONO
<br />If "yes;" identity an a separate page, the person or persons convicted, the court case and number,
<br />the crimes and the year convicted,
<br />15, If your firm was required to pay a premium of aloes than one percent for a performance and
<br />payment bonus on any projects} on which your firm worked at any time during thee last three years,
<br />state the percentage that your firm was required to pay. If your wish to ilk so, you may provide an
<br />explanation for a percentage rate higher than one percent, 0 -/.
<br />16, During the bast five years, has your firm ever been denied bond credit by a surety company, or has
<br />there ever been a period of time when your firm had no surety bond in place during, a project when;
<br />one was rertuired? D Yes X No
<br />17. Has Gal -OSHA cited and assessed penalties against the contractor or its associates for any
<br />"serious," "uvilltul" or 'repeat" violations of its safety or heatt:h regulations in the past five years?
<br />Yes IX No
<br />(Note; It you have filed an appeal of a citation, and the Occupational Safety and Haalth Appeals
<br />board has not yet ruled on your appeal, you need not Include Information about it,)
<br />If "yes," an a separate page describe the citations, the party against whom the citation teas made,
<br />date of citation, nature of the violation, project on which the citation was issued, owner of the
<br />project, and the amount of penalty paid. it any. State the case number and the date of any C)SHAG
<br />decislom
<br />18, Has the f-aderal Occupational Safety and Health Administration cited and assessed penalties
<br />against the contractor or Its assoulates in the past live years? El Yes 0 No
<br />jNote: It in appeal of the citation has been filed and the Appeals Board has riot yet ruled, or tbare
<br />is a court appeal pending, you need not Include information about the cita'ttlorm)
<br />If "yes," on a separate page describe the citation, the party against when) the citation was made,
<br />date of citation, nature of the vlofallon, project an which the citation was issued, owner of project,.
<br />and the amount of penalty paid, if any, State the case number and elate of any decision.
<br />Poaja 42
<br />PD Jamarkal Serview., RFP 17422
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