The C-149I form plays a crucial role for subcontractors, subconsultants, suppliers, and fabricators aiming to work with the Triborough Bridge and Tunnel Authority under a primary contractor or consultant. This comprehensive statement of qualification is designed to provide the Authority with confidential, detailed information about the potential vendor's ability to undertake specific tasks outlined in a contract. By covering general business details, including the vendor's full legal name, business address, and federal ID number, the form ensures transparency right from the start. Furthermore, it delves into the specifics of the subcontract, such as the nature of the work, material supplies, licensing, and the total amount proposed for the subcontract. It requires vendors to list their experience, completed and ongoing contracts, and references, thereby offering a clear picture of their track record. Section highlighting the labor employed, whether union or non-union, and proof of insurance criteria, emphasizes the form's role in addressing compliance and operational standards. The inclusion of legal or administrative actions elevates its importance for assessing the vendor's responsibility and ethical standards. By mandating the disclosure of Experience Modification Rates (EMR) and OSHA Frequency Rates, the C-149I form goes a step further in evaluating the vendor's commitment to safety and risk management, making it an indispensable tool for informed decision-making within the subcontracting process of the Triborough Bridge and Tunnel Authority.
| Question | Answer |
|---|---|
| Form Name | Form C 149I |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | SUBCONSULTANT, FABRICATOR, NYSDEC, thereofor |
TRIBOROUGH BRIDGE AND TUNNEL AUTHORITY
APPENDIX I
STATEMENT OF QUALIFICATION OF
SUBCONTRACTOR/ SUBCONSULTANT/ SUPPLIER/ FABRICATOR
The statements hereon are confidential and made solely for the information of the Triborough Bridge and Tunnel Authority in connection with the proposed subcontract with
Name of PRIME Contractor/Consultant
Address of PRIME Contractor/Consultant
under its general Contract No. |
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with the Triborough Bridge and Tunnel Authority. |
Type of Vendor Seeking Approval
If proposed Vendor to be approved will perform abatement, design, construction inspection and/or air monitoring work in any of the following areas, please check the appropriate box(es) and complete the applicable exhibit(s).
Asbestos Abatement
(Attach Exhibit A)
Lead Abatement
(Attach Exhibit L)
Hazardous Waste
(Attach Exhibit H)
GENERAL INFORMATION
Proposed Vendor (hereinafter "Subcontractor") Information:
1.Business Name*:
* The full legal business name must be inserted here. (If a partnership or corporation, the exact firm or corporate name as it appears in its partnership agreement or certificate of incorporation.)
2.Principal Business Address:
Street Address (No PO Box) |
City |
State |
Zip |
Country |
2A. Address and location of local office or plant where work is primarily being performed (not MTA work site). For construction, the local office. For material, address where the materials are being fabricated. If materials are being supplied from various locations, provide suppliers local place of business. If subcontract is for rolling stock or other capital equipment, provide the location where the final product assembly takes place. If this is the same address as provided in Question 2 above, leave blank.
Street Address (No PO Box) |
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State |
Zip |
Country |
2B. If this subcontract is for rolling stock or capital equipment check the box.
3. |
Federal ID# |
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Telephone # |
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If a corporation: |
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If a |
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When incorporated: |
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Date of organization: |
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President's name: |
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Names and address of partners (use additional |
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Vice President's name: |
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sheets if necessary): |
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Secretary's name: |
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Treasurer's name:
County Clerk's Office where your papers are filed:
Form
5.Desribe the work to be done under this proposed subcontract. Indicate clearly whether work involves labor only or labor and materials. List principal items of materials, if any to be furnished.
6.Are you licensed to perform this work in the location required by this contract? If so, provide license numbers and attach copies of the license. Consultants must include a copy of the license and/or registration in compliance with New York State Education Law Section 7209.
7.Total amount of the proposed subcontract (amount MUST be entered):
8. How many years of experience as a Contractor/consultant? |
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As a subcontractor/subconsultant? |
9.Give briefly, previous experience of directing officers including chief executive officer and general superintendent on similar work.
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Years of |
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Consulting |
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Name |
Position |
Experience |
Magnitude and Type of Work |
What Capacity |
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10. |
List principal contracts completed by present organization. |
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Name and Address of |
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Location |
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Contract Price |
Class of Work |
Date Completed |
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Awarding Party |
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11. |
List contracts, if any, that present organization has on hand. |
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Percent |
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Name and Address of |
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Location |
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Contract Price |
Class of Work |
Completed |
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Awarding Party |
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Form
12. Supply at least 10 references which demonstrate your ability to adequately perform the required work.
Firm Name
Telephone
Address
Contact Person
13.Labor Employed through: (specify
14.Attach proof that you meet the required minimum insurance criteria.
15.Identify all legal or administrative actions or proceedings in which the subcontractor or any shareholder, partner, principal, officer or managerial employee thereofor officer having ownership of 10% or more of the subcontractor is involved or has been involved within the last five years which were brought by the United States Environmental Protection Agency (EPA), the New York City Department of Environmental Protection (NYCDEP), the New York State Department of Environmental Conservation (NYSDEC), the United States Occupational Safety and Health Administration (OSHA) or any other agency having safety, health or environmental responsibilities or functions. State the status of each such action, proceeding and notice of violations. (Please provide an attachment if additional space is required.)
Action
Status
16. Give any supplemental information that the undersigned desires to submit.
Form
17.Proposed Subcontractor must list their Experience Modification Rate (EMR) and OSHA Frequency Rates (see frequency formula below) for the current and previous four (4) years in the space provided below. If EMR and OSHA Rates have not been calculated for all the years listed below, the proposed subcontractor will provide the information for the years available and explain why it cannot provide the information for the remaining years. (Note: If the proposed subcontractor is a joint venture, the joint venture and each firm participating in the joint venture will provide their respective EMR and OSHA Rates by making duplicate copies of this provision and insert the information for each firm. The name of the firm will be inserted at the top of the page.) (See also instruction page.) This information must be completely filled out including EMR, Name of Insurance Provider, and OSHA Frequency Rates as shown in OSHA 300. In addition, a letter from proposed subcontractor’s insurance provider confirming these EMRs for the past 4 years and a copy of the OSHA Frequency Log (OSHA 300) must be provided.
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Experience Modification Rate (EMR) |
From Insurance |
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Company |
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OSHA Frequency Rate |
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Actual hours |
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Name of Insurance |
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# of injuries in |
worked in a |
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Year |
EMR Rate |
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Provider |
OSHA Rate |
a given year |
given year |
Current Year |
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1 |
Year Ago |
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2 |
Years Ago |
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3 |
Years Ago |
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4 |
Years Ago |
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# of Injuries x 200,000 |
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OSHA Frequency Rate = |
Actual Hours Worked |
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If proposed subcontractor cannot provide EMR and OSHA Frequency Rates for all the years listed above, explain the details below.
The undersigned agrees to furnish the TRIBOROUGH BRIDGE AND TUNNEL AUTHORITY additional or supplemental information concerning financial and/or technical qualifications, when and as required.
Form
Dated
*
(Exact Name of Individual, Firm or Corporation)
(CORPORATE SEAL)
By
(Name and Title)
*The statement must be signed on this page. The proposed subcontractor, if a partnership or corporation, must sign this statement in the exact firm or corporate name as it appears in its partnership agreement or certificate of incorporation.
NOTE: If the proposed subcontractor is a corporation and this proposal is signed by an Officer other than the President or a Vice President, the proposed subcontractor shall furnish a certified copy of by law or resolution authorizing said Officer to sign, unless same has previously been furnished to the Authority.
Form
AFFIDAVIT OF VERIFICATION
STATE OF NEW YORK |
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COUNTY OF |
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being duly sworn says: I am *
the proposed subcontractor above named. I have read the foregoing statement. The same is in all respects true.
(Signature)
Sworn to before me this
day of |
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, 20 |
(Notary)
*If the proposed subcontractor is an individual, do not fill in this blank; If the proposed subcontractor is a firm, say here “a member of the firm of _________________ ”; if a corporation, say “The President (or other officer duly authorized) of the _______________ Company.”
Form