Join Our Team - Subcontractor Supplier Registration

COMPANY NAME: *

CONTACT NAME: *

PHONE: *

Fax: *

Email Address: *

What type of work are you interested in bidding with us?

Have you ever worked on a project with Blaine Construction?

Yes
No

If YES, indicate Project Name and Superintendent:

Are you licensed in your trade?

Yes
No

If Yes, indicate state(s):

Are you insured?

Yes
No

Worker's Compensation Coverage of at least $500,000 for each accident?

Yes
No

If No, please provide coverage limits:

Comprehensive General Liability Coverage of at least $1,000,000 for each occurrence?

Yes
No

If No, please provide coverage limits:

Automobile Liability Coverage on any vehicle (including hired and non-owned) totaling at least $1,000,000?

Yes
No

If No, please provide coverage limits:

Umbrella Liability Coverage of at least $1,000,000?

Yes
No

If No, please provide coverage limits:

What is your Annual Volume? *

Are you Bondable?

Yes
No

If YES, please provide amount per single project:

References: Provide 3 with phone number and email address below: