RD2.2 PREQUALIFICATION QUESTIONNAIRE, POINT SYSTEM
(see [I]:4.3.2)

Each prospective bidder must have a current and active California contractor's license at the time of the bid opening and must submit this Prequalification Questionnaire with all portions completed, including any required attachments.

The undersigned declares under penalty of perjury that all of the prequalification information submitted with this form is true and correct and that this declaration was executed in ______________________ County, California, on ________________________ .

__________________________________________
(Name and Title) printed or typed

__________________________________________
(Signature)

__________________________________________
(Firm Name)

__________________________________________
(Address)

__________________________________________
(City, State, Zip Code)

__________________________________________
(Telephone Number)

Each prospective bidder must answer all of the following questions and provide all requested information, where applicable. Any prospective bidder failing to do so may be deemed to be not responsive and not responsible with respect to this prequalification at the sole discretion of the University of California. All information submitted for prequalification evaluation will be considered official information acquired in confidence, and the University of California will maintain its confidentiality to the extent permitted by law. Any prospective bidder found to be not prequalified as a result of the bidder's answers to this Prequalification Questionnaire will receive written response from the University Facility explaining the Facility's decision. If the bidder can refute some of the facts upon which the decision was based, the bidder can request a hearing at the Facility to appeal the decision. The decision of the Facility is final and not appealable within the University of California.

1. License

Bidder must be a licensed contractor in California with a {TITLE} classification. Submit license number, classification, code, date issued, and expiration date.

Name of license holder exactly as on file with the California Contractor's State License Board:

License number: __________________________________________

License Classification:__________________________________________

License Code: __________________________________________

Date issued:__________________________________________

Expiration date:__________________________________________

2. Construction Experience

Complete a Type of Project form (see next page) for each of your firm's projects that cost more than ${ } and involved {TYPE OF PROJECT, FOR EXAMPLE: construction of a new research laboratory building, hospital, or special-purpose facility (e.g., a structure for aerospace research, testing, development, or manufacturing, with a controlled environment)} completed between {DATE} and {DATE}.

Provide the information by filling in the blank lined spaces on the form. Copy additional forms as required. {OPTIONAL} A maximum of {NUMBER} projects will be evaluated.

Please fill in all spaces. Complete the following information for {TYPE OF PROJECT} projects completed between {DATE} and {DATE}. {OPTIONAL} A maximum of {NUMBER} projects will be evaluated. (Copy additional sheets as needed.)

1. Project name:

   Address:

   Date completed:

2. University name:

   Contact:

   Address:

   Phone number:

3. Design Professional
   name:

   Contact:

   Address:

   Phone number:

4. Base contract amount: $__________

5. Final contract amount (with your firm): $__________

6. Initial contract time: __________ days

7. Time extensions: __________ days

8. Days past contract completion date (exclude authorized time extensions):

   __________ days

   Liquidated damages: __________ days

9. Building information:

   Did the project include {DESCRIBE ELEMENTS OF THE CONSTRUCTION THAT ARE NECESSARY TO DETERMINE THE EXPERIENCE REQUIRED TO SUCCESSFULLY PERFORM THE PROJECT WORK FOR WHICH PREQUALIFICATION IS SOUGHT}?

   YES______ NO ______

3. Financial Data

1. Current Assets
   1. Current assets, previous fiscal year: $

   2. Current assets, most recent quarter, this fiscal year: $

   3. Current assets, next most recent quarter, this fiscal year: $

2. Current Liabilities
   1. Current liabilities, previous fiscal year: $

   2. Current liabilities, most recent quarter, this fiscal year: $

   3. Current liabilities, next most recent quarter, this fiscal year: $

3. Total Debt
   1. Total debt, previous fiscal year: $

   2. Total debt, most recent quarter, this fiscal year: $

   3. Total debt, next most recent quarter, this fiscal year: $

4. Total Net Worth
   1. Total net worth, previous fiscal year: $

   2. Total net worth, most recent quarter, this fiscal year: $

   3. Total net worth, next most recent quarter, this fiscal year: $

4. Safety

1. Your firm's current workers' compensation Experience Modification Factor (EMF):

2. Does your firm have a written Injury and Illness Prevention Program (IIPP) that complies with California Code of Regulations, Title 8, Sections 1509 and 3203?

   YES _______ NO ______

   If yes, provide a copy of the written program.

3. State below the names of all personnel who will be permanently assigned to safety on this project (if necessary, list additional names in section 12):

   Name and Title	Specific Duties
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________
   _______________________________	_______________________________

   5. Arbitration and Litigation History

   1. List all University or Performance/Payment Bond Surety claims on all projects listed by bidder on Form A of this prequalification statement which were made through arbitration or litigation against bidder, (or, if general contractor is subcomponent of bidder against general contractor) since {DATE} in excess of ${ } for:
      • poor workmanship/incomplete performance, or
      • unexcused delays in completion.

      (Note: Claims which are unresolved but still pending are not required to be submitted)

      1. Separate claims made on individual projects shall be combined and reported as a single claim for a single project.

      2. Claims Rating Criteria and Ineligibility:

         1. Claims will be rated in the following two categories:
            1. Percentage of Recovery: Calculated by the total dollar amount recovered by University or Performance/Payment Bond sureties against contractor, divided by the total dollar amount claimed by University or Performance/Payment Bond sureties against contractor.

            2. Claims Frequency: Calculated by the total number of claims by University or Performance/Payment Bond sureties against contractor, divided by the total number of projects submitted on Form A.

         2. Ineligibility Based on Claims Record for University or Performance/Payment Bond Surety Claims Against Contractor: Contractors with a Percentage of Recovery rate of 67% or more, and a Claims Frequency rate of 33% or more will not be considered eligible to submit a bid for the project.

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      FORM A

      (Use one sheet per claim and copy this form as necessary to report all claims)

      Project Name

      Location (City & State)

      $________________________________________
      Amount of Initial Claim

      $________________________________________
      Amount Recovered by University or Surety

      Basis for Claim:

      Basis for Settlement:

      ---

   2. List all claims on all projects listed by bidder on Form B of this prequalification statement which were made by bidder, (or, if general contractor is a subcomponent of bidder, by general contractor) through arbitration or litigation in excess of ${ } for extra compensation against University since {DATE}. (Note: Claims which are unresolved but still pending are not required to be submitted.)
      1. Separate claims made on individual projects shall be combined and reported as a single claim for a single project.

      2. Claims Rating Criteria and Ineligibility:
         1. Claims will be rated in the following two categories:
            1. Percentage of Recovery: Calculated by the total dollar amount recovered by contractor against University, divided by the total dollar amount claimed by contractor against University.

            2. Claims Frequency: Calculated by the total number of claims by contractor against University, divided by the total number of projects submitted on Form B.

         2. Ineligibility Based on Record for Contractor Claims Against University: Contractors with a Percentage of Recovery rate of 33% or less, and a Claims Frequency rate of 33% or more will not be considered eligible to submit a bid for the project.

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      FORM B

      (Use one sheet per claim and copy this form as necessary to report all claims)

      Project Name

      Location (City & State)

      University

      $________________________________________
      Amount of Initial Claim

      $________________________________________
      Amount Recovered by Contractor

      Basis for Claim:

      Basis for Settlement:

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   3. Claims Summary
      1. Summary of University or Performance/Payment Bond Surety claims against bidder or general contractor component submitted under Paragraph 5.a. above:
         1. Total Number of Claims $

         2. Total Dollar Amount of Claims $

         3. Total Dollar Amount Recovered $

         4. Total Number of Projects Submitted on Form A

      2. Summary of bidder or general contractor component claims against University submitted under Paragraph 5.b. above:
         1. Total Number of Claims $

         2. Total Dollar Amount of Claims $

         3. Total Dollar Amount Recovered $

         4. Total Number of Projects Submitted on Form B

      6. Surety

      1. List below the surety companies utilized by your firm since {DATE}. List the surety's name, address, year used, and the number of times the surety had to complete any part of bidder's work. Provide information on a company letterhead if more space is needed.

         Surety Name	Address (City and State)	Period Covered (Year)	# Jobs Surety Completed
         ________________________	_____________________________	__________	__________
         ________________________	_____________________________	__________	__________
         ________________________	_____________________________	__________	__________
         ________________________	_____________________________	__________	__________
         ________________________	_____________________________	__________	__________

      2. Attach a declaration from surety or sureties (sureties must be listed in the latest published State of California, Department of Insurance list of "Insurers Admitted to Transact Surety Insurance in this State") proposed to be utilized on the {PROJECT NAME} certifying that bidder's bonding capacity available for this project is ${ }. Attach a copy of the surety's power of attorney.

      7. Insurance

      The successful bidder for this project will be required to furnish certificates of general liability insurance on the University's form in the minimum amounts of ${ } per occurrence and${ } in the Aggregate, and ${ } business automobile liability.

      1. State the insurance limits your firm will be able to obtain for this project:

         General liability: $ ___________________

         Business automobile liability: $____________________

      2. Provide letters from your insurance carriers stating that your firm is able to obtain the above required insurance limits.

      8. Affirmative Action

      1. Provide a copy of your firm's affirmative action program.

      2. Provide a copy of your firm's affirmative action program for the use of subcontractors and suppliers that are Small and Disadvantaged Business Enterprises (SDBEs), Small and Woman Business Enterprises (SWBEs), or Small and Disabled Veteran Business Enterprises (SDVBEs).

      9. Staff Roster

      1. List below members of your staff (except clerical staff) who will be assigned to this project, and show their job titles or functions. (Attach a separate sheet if necessary.)

      Name	Job Title/Function	Years Experience In Contracting	Years With This Firm
      ________________________	_____________________________	__________	__________
      ________________________	_____________________________	__________	__________
      ________________________	_____________________________	__________	__________
      ________________________	_____________________________	__________	__________
      ________________________	_____________________________	__________	__________

      10. Quality Assurance

      • Provide a copy of your firm's quality assurance program.

      11. Prior Disqualification

      1. Provide the following information if your firm has ever been disqualified from performing work for the University of California:
         1. Facility:

         2. Project name:

         3. Date of disqualification:

         4. Duration of disqualification:

         5. Reason for disqualification:

      2. Provide the following information if your firm has ever been disqualified from performing work for any contracting entity other than the University of California:
         1. Name and telephone number of contracting entity:

         2. Project name:

         3. Date of disqualification:

         4. Duration of disqualification:

         5. Reason for disqualification:

         (Repeat items 11.a. and 11.b. for each disqualification.)

      12. Contractor's Comments

      The following space is provided for further explanations of the answers to any questions asked in this Prequalification Questionnaire.

      Rating Information

      A contractor who receives {NUMBER} or more points out of a possible {NUMBER} points based on a pre-established rating system will be issued bidding documents and will be allowed to submit bids for the project. A contractor who receives {NUMBER} or fewer points, or who falls under any of the following categories will be excluded from submitting bids:

      1. Contractor does not have the proper license.
      2. Contractor has not completed at least {NUMBER} contracts costing in excess of ${ } per contract since {DATE} involving construction of {TYPE} projects.
      3. Contractor does not have the required financial ratios.
      4. Contractor does not meet safety requirements.
      5. Contractor exceeds ratio established for arbitration or litigation claims.
      6. Contractor does not meet pre-established minimum standards for bonding capacity (as described in the Prequalification
      7. Questionnaire).
      8. Contractor has had a surety finish work on a contract since {DATE}.
      9. Contractor is not able to obtain required insurance.
      10. Contractor does not have an affirmative action program.
      11. Contractor does not have a quality assurance program.
      12. Contractor is presently disqualified from performing work for the University of California or another University
      13. Contractor did not submit required information.

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