ࡱ> MPL_ bjbjڿڿ >:-b-bw f f 8.4b\55555555$u7+:8585M5oooR5o5oo]1C3zO)v24c50528:w:033&:4o8585a5:f B :  ADDITIONAL FINANCIAL AND INSURANCE REQUIREMENTS FOR SELF-BONDING PROGRAM FOR (Project Name) P. C. # _______________ I. GENERAL INFORMATION 1. Submitted to (agency): 91Ƭ Address: Facilities Planning Design and Construction Division 115 Grigsby Drive, Suite C Williamsburg, VA 23185 2. Name of Project (if applicable):___________________ and Project Code Number PC#:___________________ 3. Contractor's Name: Mailing Address: Street Address: (If not the same as mailing address) Telephone Number: ( ) Facsimile Number: ( ) Contact Person: Contact Person Phone Number: ( ) State Contractor's License Number: Designated Employee Registered with the Virginia Board for Contractors: II. BONDING: This project has been determined to be eligible to utilize the Commonwealths Self-Bonding Program and has a value of under $500,000. For this project, the contractor must also fill out this Attachment Two to the CO-16. III. REFERENCES: Bank or Financial Institution Name of Bank/Institution: Address: Phone Number: Contact: Copy of your current business credit report from any one of the national credit reporting companies or Dun & Bradstreet: Contact Information for Three (3) Comparable Past Projects Project Name: Project Address: Size of Project such as: (gross square feet, height, or stories plus sub-surface levels, total cost) Owner's Name: Address: Phone Number: Contact: Project Name: Project Address: Size of Project such as: (gross square feet, height, or stories plus sub-surface levels, total cost) Owner's Name: Address: Phone Number: Contact: Project Name: Project Address: Size of Project such as: (gross square feet, height, or stories plus sub-surface levels, total cost) Owner's Name: Address: Phone Number: Contact: Contact Information for Three (3) Major Suppliers Project Name: Project Address: Size of Project such as: (gross square feet, height, or stories plus sub-surface levels, total cost) Supplier's Name: Address: Phone Number: Contact: Project Name: Project Address: Size of Project such as: (gross square feet, height, or stories plus sub-surface levels, total cost) Suppliers Name: Address: Phone Number: Contact: Project Name: Project Address: Size of Project such as: (gross square feet, height, or stories plus sub-surface levels, total cost) Supplier's Name: Address: Phone Number: Contact: IV. INSURANCE Please have your Insurance Company complete the following information. For selected projects between $100,000 and $500,000, the agency has elected to offer bonding through the Commonwealths Self-Bonding Program. Insurance Company's name: Address: Representative: Is the Insurance Company licensed to transact business in the Commonwealth of Virginia? Yes ___ No ___ Policy Number, effective and expiration dates Policy Limits Attach a certificate of insurance for record V. INDEMNITORS Provide a list of financially responsible parties associated with your business. Include: Name Address Date of Birth Social Security or Federal Tax Identification Number Spouses name Date of Birth Social Security or Federal Tax Identification Number VI. SIGNATURE By: Name: ___________________________ Title: __________________________________ Signature: _______________________________________ Date: ________________     DGS-30-174 91Ƭ CO-16 (Rev. 02/12) Attachment Two PAGE 1 12JKOP\]^fuvwz3 X k }w}pdhLFh@#5>*CJ h@#5CJ h9CJhh-Ahh-ACJ hh-ACJ huCJhLFhLF5>*CJhLFhu5CJ huCJhqhCh 56CJ hh-A>*aJhqhCh 5CJhqhCh >*CJhh-Ahh-A5B*ph3hqhCh 5 hP5CJ hLF5CJ h@#5CJ'2KO^vw 4 5 l  0|L |`|gdh-A 0|L |`|gdu 0|L `gdu 0|L gdugdLF$a$gdCh $a$    ! > ? 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PLP^P`LhH. 8-{~$hW3Uu&B3+>F/G a @ 0^`0OJQJo(          p                                    G:        Pޒ                 Tf)#.43lCh S Ium7.8@#t\# &m+ .s5cU<h-Am%CtELFriL-V&[D_ h&i$nwXn~"vp{GU"r" P0}H59RQ y*TQd<9-$^w y @@UnknownG.[x Times New Roman5Symbol3. .Cx Arial5. .[`)Tahoma7.*{$ Calibri?= .Cx Courier New;WingdingsA$BCambria Math" h hg hgu u ! q q 2q HP ?p{2!xxs CO-16 ATTACHMENT TWOSELF BONDING FORMS Mike CoppaRodriguez, Juan0         Oh+'0     CO-16 ATTACHMENT TWOSELF BONDING FORMS Mike CoppaThe 2-15-2012 update changed the definition of Credit Report in Part III and changed the data needed to identify the Indemnitors in Part V.NormalRodriguez, Juan2Microsoft Office Word@G@6)@6)u  ՜.+,0 hp|  DGSq  CO-16 ATTACHMENT TWO Title  !"#$%&'()*+,-./0123456789:;=>?@ABCEFGHIJKNORRoot Entry F0^zO)Q@1Table;WordDocument >:(<DocumentSummaryInformation8DMsoDataStoreyO)zO)0TG15ZWRPMBAA==2yO)zO)Item PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q