Please complete and submit the following prequalification form as needed to provide a basis for the evaluation of your firm’s qualifications to work with Andersen Construction.

If you would prefer to complete this form off-line, please click on the PDF download link below, print the form and mail it back to us at the following address:

Andersen Construction Company
6712 N. Cutter Circle
Portland, Oregon 97217
Attention: Estimating Department

Download Prequalification form (PDF)

GENERAL INFORMATION
Business Name 
Street Address 
main
branch office
P. O. Box 
City 
State 
Zip Code 
Telephone 
Fax 
EMail 
Contact Person 
Title 
Date Founded 
State of Business Registry 
Business Organization: 
C Corporation 
S Corporation 
Partnership 
Sole Proprietor 
LLC 
Certified As:
MBE 
DBE 
WBE 
ESBE 
Other 
Certification No. 
SIC Code 
Subcontractor No. (by Andersen) 
FEIN 
Prior Business Names 
Are you a subsidiary of 
a parent company 
Yes
No
or do you have a subsidiary 
of your company 
Yes
No
If “Yes” to either, please 
provide clarification. 
LIST YOUR WORKERS COMPENSATION POLICY INFORMATION
Carrier   Policy #   State
LICENSE INFORMATION — indicate licenses you hold that are required for you to perform your services
License Type/Name   State   Number
WORK EXPERIENCES, PREFERENCES
Provide a list of major projects in progress, and a list of major projects completed in the last three years, indicating project name and location, owner, architect/engineer, general contractor and contact person, subcontract amount and completion date.
Type of work normally performed with own employees
Identify geographic area you would work in
Has your firm ever failed to complete any work awarded?
Yes
No.  Explain as necessary.
Has your firm, or any firm with which a principal has been involved in a management role ever filed for bankruptcy?
Yes
No.  Explain as necessary.
Are there any judgements, claims, arbitrations or suits pending or outstanding against your company or any of its principals?
Yes
No.  Explain as necessary.
Has your firm filed any law suit, or requested arbitration or mediation with regard to its construction contracts within the last three years?
Yes
No.  Explain as necessary.
What was your dollar volume each of the last three years?
Year  
Year  
Year  
What is your current backlog dollar value? 
Union Shop? 
Yes
No.
Current number of employeers:
Office 
Field 
Shops 
FINANCIALS
Provide your most current financial statement by cutting and pasting it into the space below.
Bank Reference 
Contact Person   Telephone 
Bonding Company 
Contact Person   Telephone 
Bond Limits Per Project  
  Aggregate 
REFERENCES
Owner, General Contractor or Subcontractor:
Name   Affiliation   Telephone No.
SAFETY, HEALTH AND ENVIRONMENTAL
Provide your written company safety program and substance abuse policy by cutting and pasting it into the space below.
Provide the number of cases in each category from your three most recent years OSHA No. 200 or 300A.
 (Yr)    (Yr)    (Yr)
Fatalities
Lost day Cases
Number of lost time accident cases
Number of Restricted Workday Cases
Number of other recordable cases
No. of Actual Employees Hours Worked 
Identify and describe each of the major OSHA citations you have received in the last three years.
What were your General Liability (CGL) loses for each of the last three years?
Year  
Year  
Year  
Questionnaire completed by:
Name 
Title 
 
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