Chanen Construction prequal Page 3
PART III
SURETY OR CARRIER NAMES
PAYMENT AND PERFORMANCE BOND
If this is section is left blank, you will not qualify.
Payment and Performance Bonding Carrier________________________________
Bonding Capacity:
Single ____________________Aggregate______________________
WORKERS COMPENSATION:
Worker's Compensation Carrier Name____****_______________________________________
***Please provide a copy of your current insurance certificate with the
endorsements and additional insured.
Worker's Compensation Experience Modification Factor:_____________________________
GENERAL LIABILITY: (with Exhibit E-1 Supplement and Insurance Certificate)
General Liability Carrier Name_______***__________________________________________
******Please provide a copy of your current insurance certificate with the
endorsements and additional insured.
To be qualified, your company must have the minimum coverages referenced in "EXHIBIT E". Please
forward the both "Exhibit E-1 and Exhibit E" to your insurance agent/broker to be completed and faxed
back with your update.
Page 3 of 8
