Omni Pinnacle / Subcontractor Form

Subcontractor Form

Insurance Form

Subcontractor Form

We request that anyone wanting to work with OMNI Pinnacle, LLC as a Subcontractor, complete the Subcontractor Form by either filling out the online form below, or printing the form, and faxing the completed form to 985-643-4334.

Printable Subcontractor Form

Contact Information

Company Name

Address

City

State

Zip Code

County

Contact Name

Contact Phone 1

Contact Phone 2

Contact Fax

Email Address

Company Website

Company Background

Nature of work performed

Geographical Areas Willing to Work:

Entire NE

Entire SE

Entire NW

Entire MW

Entire US

Other

Additional States

Describe Previous Work

Social Economic Status
Check appropriate box, and if applicable list SBA Certificate Number and, if a Minority Owned Business, please list national origin.

Small Business

Small Disadvantaged Business

Hubzone Small Business

Women Owned Small Business

Veteran Owned Small Business

Large Business

Other

Certificate Number:
(List all Cert. #s)

Principal Name

Do you use Leased Employees, Direct Hire, or Both?

Leased

Direct Hire

Equipment

Specify number of pieces for each:

Skid Steer Loader
With Grapple Bucket

Front End Loader
With Grapple Bucket

Dump Trucks
40 to 79 Cubic Yard Capacity

Dump Trucks
80+ Cubic Yard Capacity

Dump Trailers

Self-Loading Grapple Trucks
Up to 40 Cubic Yard Capacity

Self-Loading Grapple Trucks
40+ Cubic Yard Capacity

Excavators

Excavators with Grapple Bucket

Graders

Scrapers

Tub Grinders

Chippers

Flat Beds

Low Boys

Tractor Trucks

Fuel/Service Trucks

Air Curtain Burner

Other Equipment
+ Number of Pieces

Insurance Information

Can you comply to meet our minimum insurance requirements listed below? Please check "Yes" or "No" for each. Please note that standards may increase to comply with prime contract requirements.

General Liability
Each Occurrence $1,000,000:

Yes
No

General Liability
Aggregate $2,000,000:

Yes
No

Auto Liability
$1,000,000:

Yes
No

Worker`s Comp Statutory:

Yes
No

If NO, Amount

General Liability Carrier

General Liability Amount

Auto Carrier

Auto Amount

Worker`s Comp Carrier

Worker`s Comp Amount

Excess Liability Carrier

Excess Liability Amount

Experience Modifier

Incident Rate

Can you finance work up to 45 days:

Yes
No

Have you worked with us before:

Yes
No

If Yes, when and where?

No. of crews you expect to provide

Have you had any disputes within the last three years with a client/owner/contractor in which either arbitration or litigation was initiated?

Disputes within last three years:

Yes
No

If Yes, explain:

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