MASSACHUSETTS BAY TRANSPORTATION AUTHORITY
CONTRACT ADMINISTRATION
TRANSPORTATION BUILDING
TEN PARK PLAZA, ROOM 6720
BOSTON, MASSACHUSETTS 02116
TEL: (617) 222-3133
FAX: (617) 222-5299
*** CONTRACTOR PREQUALIFICATION STATEMENT***
COMPANY NAME: ______________________________________________
___Individual
___Corporation
___Joint Venture
___Other: ____
ADDRESS: _____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
TELEPHONE: ___________________________________________________________________
FAX #: __________________________________________________________________________
PRINCIPAL OFFICE: _____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTACT PERSON: _________________________ TELEPHONE #: ______________________
EMAIL ADDRESS:
END OF FISCAL YEAR: ______________________DATE PREPARED: ____________________
DATE RECEIVED
BY MBTA: _____________
January 2012
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Massachusetts Bay Transportation Authority
INSTRUCTIONS
Contractors proposing to bid on Massachusetts Bay Transportation Authority’s work totaling $1,000,000 or more must
complete a Prequalification Statement and submit it in proper form at least ten (10) calendar days prior to bid opening.
Forms should be typed or printed in black ink. All seven (8) parts of the form must be thoroughly completed. Failure to
provide requested information may prohibit the Authority from prequalifying your firm on a timely basis. The seven parts
are as follows:
I. EXPERIENCE
II. EQUIPMENT SCHEDULE
III. ORGANIZATIONAL STRUCTURE
IV. FINANCIAL DATA
V. REQUEST FOR ATTORNEY’S LEGAL LETTER OF LIABILITIES
VI. MANAGEMENTS STATEMENT OF REPRESENTATION TO EVENTS
SUBSEQUENT TO THE BALANCE SHEET DATE
VII. AFFIDAVIT TO PREVIOUS STATEMENTS
VIII. SAFETY RECORD
The signatory of this Prequalification Statement guarantees, as evidenced by the notarized statement herein required, the
truth and accuracy of all statements and of all answers to the interrogatories hereinafter made.
General Information when filling out the work history forms:
 All eight parts of the statement must be thoroughly completed. Failure to provide the requested information may
prohibit the committee from prequalifying the company.
 All projects provided on the work history forms must be a completed and should not have a completion date
exceeding ten (10) years from the date of the contractor’s request for prequalification.
 Work history forms must be typed or printed in black ink. Typed forms are preferred using font sizes of no less than
8 or no more than 12. Please number your work history sheets.
 When requesting a particular class of work, the project stated on the work history form must demonstrate the said
requested class of work was performed by describing in detail the services to support class of work requested.
 The value of the construction dollar amount of each class of work (class 2 – 16) shall not exceed the contract
amount. Class 1 work is the percentage (%) of the total contract amount that is performed by a contractor when
operating in or around an operating rapid transit, light rail, commuter rail and freight right-of-way without causing
disruption to service.
Additional information can be obtained on the prequalification process by referring to: MBTA’s Procedures Governing
Classification and Rating of Prospective Bidders which may be obtained from the Contract Administration Office, 10 Park
Plaza, Room 6720, Boston, MA 02116.
QUESTIONS
If you have questions, please call the Contract Administration Office at (617) 222-3133.
Submit completed forms to:
Director of Construction - Contracts
Massachusetts Bay Transportation Authority, Contract Administration, Transportation
Building, Ten Park Plaza, Room 6720, Boston, MA 02116
CONFIDENTIALITY
O W N E R S H I P OF I N F O R M A T I O N
The completed prequalification statement shal1 be the exclusive property of the prospective bidder and as such shall not
constitute a portion of the records of the Authority and shall not be open to public inspection.
All information furnished in any statement by a prospective bidder shall be held in strict confidence by the Authority and
its agents, except where such information is required by statute and/or regulations promulgated by applicable Federal or
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Massachusetts Bay Transportation Authority
State agencies, and such information shall be used only to determine the prospective bidder's Prequalification Certification
in accordance with the procedures herein contained. No information contained in any such statement shall be imparted to
any other person without the written consent of the prospective bidder.
C H E C K L I S T P R I O R TO S U B M I T T I N G
INCLUDE:
____ Surety letter with Power-of-Attorney signing authorization
_____ Auditor's opinion, signed and dated, Balance Sheet, Income Statement and footnotes
_____ Massachusetts Corporate Annual Report signed by Officer and dated for current fiscal period
_____ Attorney legal Letter of Liabilities
_____ Safety Record, OSHA Form 300 Summary- Contractors must provide all OSHA Reportable incidents within the
last five (5) years using the Form 300 Summary Log of Injuries and Illnesses. The form can be downloaded from
OSHA’s website at:http://www.osha.gov/recordkeeping/new-osha300form1-1-04.pdf
On Affidavit:
_____ Have Officer sign affix corporate seal and notarized.
Note:
Contract Administration has a comparable checklist, which must be completed before Prequalification is granted.
This checklist is for internal use only.
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Massachusetts Bay Transportation Authority
PART I – EXPERIENCE
1. How many years has your organization been in business as a general contractor under your present business
name? __________________________
2. Indicate with an X below the class(es) of work for which prequalification is requested and record the number of years
of the organization’s experience as a general and sub-contractor.
Class
Years
Gen’l. Sub.
Years
Gen’l. Sub.
Class
(1) ___ General Transit Construction
____
____
(6) Signaling
(1a) ___ Marine General Transit
Construction
____
____
____ (a) Transit/Railroad
Signaling
____
____
(2) ___ Grading, Drainage & Site
Development
____
____
____ (b) Traffic Signaling
____
____
(3) ___ Trackwork
____
____
(4) Bridges1:
(7) ____
Buildings3
____
____
(8) ____
Demolition
____
____
___ (a) Steel Superstructures
____
____
(9) ____
General Tunneling
____
____
___ (b) Concrete Superstructures
____
____
(10) ____
Mechanical
____
____
___ (c) Complex Bridges2
____
____
(11) ____
Asbestos Abatement4
____
____
____
____
(12) ____
Precast Concrete
____
____
(5) ___ Electrical
1
If the company is prequalified in any bridge classification under Mass Dot, please provide certification.
2
Additional prequalification requirements will be provided in public advertisement.
3If
the Contractor is certified by the Department f Capital Asset Management - DCAM in Buildings, please
provide Certificate with Statement.
4
An additional Prequalification Form is required for asbestos abatement. This form is available from Contract
Administration
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Massachusetts Bay Transportation Authority
3.
List below the major projects of the type of work you wish to bid on, that your organization has completed within the last ten years. For Class
of Work descriptions and identification numbers, please refer to the listing in Appendix 1 of the Procedures Governing Classification and Rating
of Prospective Bidders. The Contractor must follow the example that is provided including all columns. List the most recent and highest
contract valued projects first.
Contract
Amount
$123,456,789.
% of
Contract
completed
by your
firm
65
Project Title and
Location
Owner/
Contact Name/
Phone Number
Completion
Date
1
$50,000,000.
% of each
Class of
Work
performed
by your
firm
50
2
3
7
$20,000,000.
$10,000,000.
$40,000,000.
50
100
75
Class of
Work
Dollar
Amount of
each Class
Work
Detailed Description of Work
E X A M P L E
North Station Green
Line Improvement
Project, Track &
Station Rehabilitation
MBTA
Robert Egan
617.222.5910
October
2002
Platform reconfiguration and extension to
accommodate 6 car trains.
Site grading, installation of drainage.
Installation of 400 feet of track.
Erected 2 headhouses. Work performed while
trains were in operations. The work required
use of flagmen.
This Project is a
SAMPLE for
Contractor
consideration
December 2011
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Massachusetts Bay Transportation Authority
PARTI –EXPERIENCE - Cont'd
4. Has a bond ever been invoked against your firm?__________________________
If so, where and why? Include pertinent information; i.e., date, project name, owner's name, and reason thereof
5. Have you ever failed to complete any work awarded to you?
If so, where and why? Include date, project name, owner's name, and reason thereof
6. Has any officer or partner of your organization ever been an officer or partner of some other organization that failed
to complete a contract? ________________________________
If so, state name of individual, other organization, reason therefor and bonding company.
7. Has any officer or partner of your organization ever failed to complete a contract handled in his/her own
name?_______________
If so, state name of individual, reason therefore and bonding company.
8.
In what other lines of business are you affiliated with (directly or indirectly)?
9.
With what person (or persons) have you been associated as a business partner or otherwise during the past five years?
10. Did you complete your last three contracts on time as well as the major ones listed in Question 3?
______________________________ If not, why?
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Massachusetts Bay Transportation Authority
PART 1- EXPERIENCE
11. What is the construction experience of the principal officers of your organization? If the principal officers are lacking
in construction experience, list the experience of the individuals who will be your field superintendents on the
proposed work in Massachusetts.
YEARS OF
INDIVIDUAL’S NAME
PRESENT
POSITION
CONSTRUCTION
EXPERIENCE
MAGNITUDE & TYPE
OF WORK
IN WHAT CAPACITY
Part II- EQUIPMENT SCHEDULE
Total Value (At cost less depreciation)
$
DEPRECIATION
DESCRIPTION
PRESENT
CONDITION
SIZE OR
CAPACITY
YEAR MFG.
YEAR
PURCHASE
PURCHASED
PRICE
CHARGED
OFF
COST
LESS
DEPRECIATION
* Show: Make, Model No., Serial No., How Equipped
(a separate schedule may be attached)
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Massachusetts Bay Transportation Authority
PART III- ORGANIZATIONAL STRUCTURE
CORPORATIONS
INDIVIDUALS PARTNERSHIPS OTHERS
When Incorporated
Type of Entity:
In What State?
Date Organized:
President’s name:
Principal’s Names
And Address:
Vice President’s Name
Secretary’s Name:
Treasurer’s Name
PART IV - FINANCIAL DATA
BONDING:
A contractor is required to submit annually a letter from its surety confirming its current bonding capacity. Confirmation will not be
accepted unless the insurance company is licensed and approved by the Massachusetts Division of Insurance and is rated B+ or better
by A.M. Best Company. With the bonding company's letter, the bonding agent must enclose his/her Power of Attorney or AttorneyIn-Fact signing authorization document issued by the insurance company.
Indicate the firm's bonding limit per project and the firm's aggregate bonding capacity.
Single Project Limit
Aggregate Bonding Capacity
Attach letter from surety or bonding agent confirming above limits. (Include with letter attorney-in-fact signing authorization.)
Indicate name of present bonding agent, contact person, address, and telephone number.
Agent Name:
Address:
Contact Person:
Telephone Number:
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Massachusetts Bay Transportation Authority
PART IV - FINANCIAL DATA - Cont'd
Attach the latest fiscal-year-end audited financial statements and footnotes. A full opinion audit must have been conducted
in accordance with generally accepted auditing standards. Financial statements should include auditor's opinion, balance
sheet, income statement and notes.
MASSACHUSETTS CORPORATION ANNUAL REPORT/A.K.A. CERTIFICATE OF CONDITION
Has the corporation filed its current Massachusetts Corporation Annual Report or the Massachusetts Foreign Corporation
Annual Report, with the Office of the Secretary of State. (Due annually two and one-half months following the close of
the fiscal year)?
If so, a copy of the report signed and dated by an officer of the corporation must accompany this Prequalification package.
The date of the fiscal year appearing on this report should agree with the date of the Balance Sheet accompanying this
report.
If the report has not been filed, explain why, and attach a copy of the most recent filing signed and dated by an officer of
the corporation.
PART V- REQUEST FOR ATTORNEY'S LEGAL LETTER OF LIABILITIES
In connection with the examination of your financial statements accompanying the Prequalification Statement, will you
please have your legal counsel list, if any, a description and evaluation of any litigation, impending litigation, claims and
contingent liabilities of which you have knowledge that existed at the date of the balance sheet being reported on, plus any
additional matters of such nature coming to his attention up to the date the information is furnished.
The above request should contain the following information (1) the nature of the litigation (2) the progress of the case to
date (3) an evaluation of the likelihood of an unfavorable outcome and an estimate, if one can be made, of the amount or
range of potential loss and (4) if particular cases have been filed in court, provide name of court and docket number.
Please furnish to the Massachusetts Bay Transportation Authority such explanation, if any, that you consider necessary to
supplement the foregoing information, including an explanation of those matters as to which your views may differ from
those stated and an identification of the omission of any pending or threatened litigation, claims and assessments or a
statement that the list of such matters is complete.
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Massachusetts Bay Transportation Authority
PART VI
- MANAGEMENT'S STATEMENT OF REPRESENTATION TO EVENTS SUBSEOUENT TO THE
BALANCE SHEET DATE
For the period subsequent to the balance sheet date of the statements accompanying this prequalification statement to date of signing
the affidavit in Part VII.
We confirm that
1. We are responsible for the fair presentation in the financial statements of financial position, results of operations, and changes
in financial position in conforming with generally accepted accounting principles.
2. There have been no.
A. Irregularities involving management of employees who have significant roles in the system of internal accounting
control.
B. Irregularities involving other employees that could have a material effect on the financial statements.
C. Communications from regulatory agencies concerning noncompliance with, or deficiencies in, financial reporting
practices that could have a material effect on the financial statements.
3. No events have occurred or are planned having a material effect on the carrying value or classification of assets and
liabilities.
4. There has been no significant change in:
A. Capital stock repurchase options or agreements or capital stock reserved for options, warrants, conversions, or other
requirements.
B. Arrangements with financial institutions involving compensating balances or other arrangements involving restrictions
on cash balances and line-of-credit or similar arrangements.
C. Agreements to repurchase assets previously sold.
5. There has not arisen:
A Violations or possible violations of laws or regulations whose effects should be considered for disclosure in the financial
Statements or as a basis for recording a loss contingency.
B. Other material liabilities or gain or loss contingencies that are required to be accrued or disclosed by statement of
financial accounting standards No.5.
C. Unasserted claims or assessments that our lawyer has advised us are probable of assertion and must be disclosed in
accordance with statement of financial accounting standards No.5.
D. Any unusual adjustments to the books of account
E. Significant change in working capital or long term debt.
6. The company has satisfactory title to all owned assets, and there are no liens or encumbrances on such assets nor has any
asset been pledged except as disclosed in the accompanying footnotes to the financial statements.
7. There is no material loss to be sustained as a result of purchase commitments for inventory quantities in excess of normal
requirements or at prices in excess of the prevailing market prices.
8. The company has complied with all aspects of contractual agreements that would have a material effect on the financial
statements in the event of noncompliance.
9. No events have occurred subsequent to the balance sheet date that would require adjustment to, or disclosure in, the financial
statements.
Please provide an explanation of those items that cannot be confirmed. Unless otherwise noted, confirmation of the above is attested to
in the signing of the affidavit in Part VII.
Explanation Attached
December 2011
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Massachusetts Bay Transportation Authority
PART VII - AFFIDAVIT TO PREVIOUS STATEMENTS
State
SS:
Country:
The undersigned contractor(s) being duly sworn, depose and say that statements and answers to all questions herein
contained and representations made subsequent to the balance sheet date contained in Part VI are true and correct. That
this statement is for the express purpose inducing the party to whom it is submitted to award the submitters a contract, and
that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information
necessary to verify this statement.
Firm Name
Name of Chief Executive Officer
Or Chief Financial Officer
Title
Officer’s Signature
Date
SIGNATURF FOR JOINT VENTURE
Firm Name
Name of Chief Executive Officer
Or Chief Financial Officer
Title
Officer's Signature
Title
NOTARY:
SWORN TO BEFORE ME THIS _________DAY OF __________YEAR__________
NOTARY PUBLIC
MY COMMISSION EXPIRES:
IF CORPORATION,
AFFIX CORPORATE SEAL(S)
PART VII- SAFETY RECORD (Provide Contractors safety record for the last five (5) years using the OSHA 300Form Summary.
The Form 300 can be downloaded from OSHA’s web site: http://www.osha.gov/recordkeeping/new-osha300form1-1-04.pdf
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Massachusetts Bay Transportation Authority