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General Information
Company Name
FEIN #
Address*
Address Line 2
City*
State*
Zip*
Main Phone
Fax
Website
Main Construction Division
Check All That Apply
- Site Work
- Concrete
- Masonry
- Metals
- Woods & Plastics
- Thermal & Moisture Protection
- Doors/Windows/Hardware
- Finishes
- Specialties
- Equipment
- Furnishings
- Special Construction
- Conveying
- Mechanical
- Electric
- Other
Primary Contact
Primary Contact
Title
Direct Phone
Email
Estimator Contact
Estimator
Direct Phone
Email

Insurance & Bonding
Insurance Company
Contact Name
Liability Limit - Each Occurrence
Liability Limit - Umbrella
Bonding Agent
Bonding Limit
Contact Name
Phone
Regions of Work
Michigan Areas
Other Regions
Divisions of Work
CSI Divisions
Descriptions / Comments
Types of Work
Select All That Apply
- Office
- Manufacturing
- Industrial / Distribution
- Healthcare
- Senior Living
- Educational
- Retail
- Residential / Hotel
- Other
If Other, Please Elaborate:
Certifications
Type of Labor: Self Perform %
Type of Labor: Subcontract %
Select All That Apply
- Open Shop
- Union
- National Union Agreement
- Local Union Agreement
- Prevailing Wage
Other Type Labor
Union Information
Classifications
- WBE
- SBE
- MBE
- State
- DBE
- Federal
- VBE
- Other Classification

Legal / Financing
Type of Business
- Proprietorship
- Corporation
- Partnership
Years in Business
Number of Employees
State Incorporated In
Licenses - Type & Registration Number
Financial Statement Available?
- Yes
- No
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Bank
Contact Name
Phone
Litigation
Principals
Owner(s)
Subsidiaries

Work History
% of Work as GC
Please enter a number from 0 to 100.
% of Work as Subcontractor
Please enter a number from 0 to 100.
% of Work Subcontracted Out
Please enter a number from 0 to 100.
Maximum Contract Value
Maximum Time Under Contract
Average Annual Work Value
Safety
Do you have a Safety Program?
- Yes
- No
Person Responsible for Program
Phone
Lost Work Days Last Year
Fatalities Last Year
Average Lost Days Last Five Years
Average Fatalities Last Five Years
Incidents of Medical Treatment Last Year
Experience Modification Rate (EMR) - Current Year
Experience Modification Rate (EMR) - Previous Year
Experience Modification Rate (EMR) - Previous Year
Safety Record Comments
References / Project List
References / Projects
Submission Information
The undersigned hereby certifies that the information provided on this form accurately references the state of the organization. KIRCO MANIX Construction, LLC. will use this information for qualification purposes only.*
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Information Provided By*
Email*
Title*
Date
MM slash DD slash YYYY
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Comments
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