THE METROPOLITAN ST. LOUIS SEWER DISTRICT
2350 Market Street
St. Louis, MO 63103
Attn: Purchasing Department
Amanda Cooper (314) 768-6329
or
Lisa Treat (314) 768-6269
2015 - 2016 CONSTRUCTION PRE-QUALIFICATION QUESTIONNAIRE
(USED IN PRE-QUALIFYING BIDDERS ON CAPITAL CONSTRUCTION WORK)
___________________________________________________________
SUBMITTED BY (COMPANY)
___________________________________________________________
ADDRESS
___________________________________________________________
CITY, STATE, ZIP CODE
___________________________________________________________
DATE
___________________________________________________________
CONTACT NAME (FOR QUESTIONS) - TELEPHONE & FAX
TAX ID NUMBER
_____________________________________________________________
E-MAIL ADDRESS
Page 1 of 33
rev. 6/17/15
PREQUALIFICATION CHECK LIST
Below is a checklist of required documentation
 Signed application and boxes checked indicating type of work requested – (Page 9).
 Signed Conflict of Interest Statement (Page 5).
 Bonding capacity indicated (Page 10)
 Equipment Sheet is complete (Page 26)
 Affidavit is complete with Notary Seal for whichever type of business is applicable.
 Attach Certificate from the Secretary of State showing company is authorized to transact
business in the State of Missouri.
 Attach ACCORD Certificate of Insurance with MSD as certificate holder (pages 27-30).
 Attach drain layers license for City of St. Louis and/or St. Louis County (required for Sewer
Construction and Deep Sewer Construction categories)
 Demolition work for MSD within the City of St. Louis – attach certification for specific
classification.
o Class I – no building size restrictions.
o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet
area/200,000 cubic feet volume.
o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no
demolition license.
o St. Louis County does not require license.
Page 2 of 33
rev. 6/17/15
RULES AND REGULATIONS FOR PREQUALIFICATION OF CONTRACTORS
ON WORK LET BY CONTRACT WITH
THE METROPOLITAN ST. LOUIS SEWER DISTRICT
1.
An applicant for pre-qualification must furnish, under oath, detailed information with
respect to its equipment, past record, personnel, and experience, together with other
information as is called for in this Prequalification Questionnaire.
2.
A contractor must be prequalified prior to bid opening of a project.
3.
Any combination of qualified or unqualified contractors bidding jointly becomes a new
contracting firm and it must be pre-qualified in accordance with these rules. All
applications shall be in writing and signed by the principal parties in the joint venture.
4.
Pre-qualification Questionnaire forms must be filed by October 1st of each year in order to
renew pre-qualification. This form must be completed in detail. The District may require
any additional information deemed necessary for pre-qualification. Companies prequalified within 3 months prior to this date will not need to submit a renewal application
until October 1st of the following year.
5.
No bidder will be pre-qualified unless its Pre-qualification Questionnaire indicates that it
has the experience, organization, and equipment, sufficient in the judgment of the District,
that it can satisfactorily execute its contracts and meet its obligations therein incurred.
6.
The Financial Statement of the controlling individual or corporate owner of the business
shall be submitted; if in the opinion of the District it is required.
7.
If any significant change occurs in the information included on the contractors’ prequalification form, notice shall be given to the District immediately.
8.
All corporations must furnish a certificate from the Secretary of State showing that it is
authorized to transact business in the State of Missouri
9.
A copy of your firm's Certificate of Insurance meeting the Districts coverages is required.
10. A copy of the applicable drain layers license from the City and/or County of St. Louis is
required for Sewer Construction or Deep Sewer Construction.
11. Demolition work for MSD within the City of St. Louis – attach certification for specific
classification.
o Class I – no building size restrictions.
o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet
area/200,000 cubic feet volume.
o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no
demolition license.
o St. Louis County does not require a license.
NOTE: It is important that the work experience pages in Section V be completed and that it
contains projects of the type for which pre-qualification is being requested. Prequalification will not be granted for types of work that you subcontract to others.
Page 3 of 33
rev. 6/17/15
IMPORTANT INFORMATION FOR PROSPECTIVE BIDDERS
1. CONTRACT DOCUMENTS
Contract documents include, but may not be limited to, the advertisement, Instructions to Bidders,
Proposal, General Specifications, Detailed Specifications, Agreement, Bond Form, and Plans. The
documents are available on and after the day advertisement is published and will be available via
MSD’s website at www.stlmsd.com. Look for a link to “ELECTRONIC PLANROOM”. Plans and
specifications are also available for viewing or purchase at Cross Rhodes Reprographics located at
1710 Macklind Avenue, St Louis MO 63110.
2. CHARGE FOR DOCUMENTS
The charge for contract documents is not refundable.
3. PREQUALIFICATION
Bidders not already pre-qualified may make application for pre-qualification to the Purchasing
Manager, The Metropolitan St. Louis Sewer District, 2350 Market Street, St. Louis, MO 63103. A
contractor must be pre-qualified prior to bids being opened.
4. SPECIAL PROVISIONS
Any special provisions or requirements concerning the work on any particular contract will be
noted in the contract documents or on the Plans.
5. MINIMUM WAGE AND EMPLOYMENT DISCRIMINATION
The minimum wage to be paid to all labor will be shown in the contract documents where
applicable. Prevailing rates of pay shall be paid to skilled and unskilled labor, and there shall be no
discrimination in the selection or employment of labor on account of race, creed, or color.
6. BID SECURITY
The bid shall be accompanied by a certified check or cashier's check drawn on a bank or trust
company located in either St. Louis City or County or by a bid bond issued by a surety company
satisfactory to the District and which is authorized to transact business in Missouri.
7. RIGHT TO REJECT
The Metropolitan St. Louis Sewer District reserves the right to reject any and all bids and to waive
technicalities.
Page 4 of 33
rev. 6/17/15
VENDOR’S CONFLICT OF INTEREST QUESTIONNAIRE
1.
Name the individual or company requesting to do business with The Metropolitan St. Louis
Sewer District (MSD).
2.
In the past two (2) years has the individual or company name in 1. above (or any principal of such
company, i.e. partner, officer, director, etc.) contributed cash or gifts in excess of $200.00 in
value in the aggregate in any calendar year to any of the individuals or organizations listed on
Attachment A hereto?
Yes
No
If yes, describe in detail (date/amount/description).
1.
In the past two (2) years, has the individual or company named in 1. above done business with
any person listed in Attachment and/or their respective companies.
Yes
No
If yes, describe in detail (date/amount/description).
4.
The undersigned certifies that the above information is true and correct to the best of his or her
knowledge and belief.
Dated this
day of _________________. 20 _
Printed Name:
_____
Title:
_____
Company Name:
_____
Signature:
_____
Page 5 of 33
rev. 6/17/15
GENERAL MANAGEMENT POLICY/PROCEDURE
Conflict of Interest
ATTACHMENT A
Updated June 1, 2014
NOTE: Attachment "A" contains a list of the MSD Trustees and their respective employer, MSD officers and
Directors, and the organizations which each are individually associated with, as applicable.
Trustee/Director
Robert T. Berry
Ruby L. Bonner
James Faul
MSD BOARD OF TRUSTEES
Name of Firm, Organization or Company
Affiliation
American Public Works Association
American Society of Civil Engineers
Circle Club of St. Louis
Engineer’s Club of St. Louis
Engineers Without Borders
Huntbridge Forest Subdivision
Manchester UMC Board of Trustees
Masonic Lodge of Missouri
Missouri Athletic Club
Missouri Botanical Garden
Missouri Society of Professional Engineers
Missouri University of Science & Technology
Missouri University of Science & Technology Academy of
Civil Engineers
Missouri University of Science & Technology Academy of
Miner Athletics
Missouri University of Science & Technology Alumni
Association
Moolah Shrine Temple
Professional Training for Engineers, LLC
Racquet Ruckus Foundation
Reserve Officers Association
Scottish Rite Bodies
U.S. Army Reserves, Retired
Water Environment Federation
Member
Member
Member
Member
Member
Secretary
Member
Member
Member
Member
Member
Adjunct Professor
Member
Alpha Kappa Alpha Sorority, Inc.
Ethel Hedgeman Lyle Foundation
Mercy Seat Metropolitan Baptist Church
Missouri Bar Association
Mound City Bar Association
NAACP
National Equal Employment Opportunity Services
Organization
National Retired Teachers Association
Sue Shear Institute
Member
Member
Member
Member
Member
Member
Mediator/Investigator
Epiphany of Our Lord Catholic Church
Lawyers Coordinating Committee
Missouri Bar Association
Missouri Jobs with Justice
St. James the Greater Knights of Columbus
St. Louis City Labor Legislative Club
St. Louis Zoo
Member
Member
Member
Member
Member
Member
Member
Page 6 of 33
Member
Member, Executive
Committee
Member
President
Chairman
Member
Member
Retired Officer
Member
Member
rev. 6/17/15
Trustee/Director
Brian Hoelscher
MSD BOARD OF TRUSTEES
Name of Firm, Organization or Company
American Public Works Association
American Society of Civil Engineers
Engineers Club of St. Louis
Labor and Employment Relation s Association; Gateway
Chapter
Missouri Water Environment Association
Water Environment Federation
Affiliation
Member
Member
Member
Member
Member
Member
Annette K. Mandel
Central West End Planning & Development Committee
Missouri Bar Association
USO Missouri
West Point Parents Club
Member
Member
Volunteer
Member
Barbara Mohn
Water Wastewater CIO Forum
Member
Susan M. Myers
Association of Corporate Counsel
Bar Association of Metropolitan St. Louis
Missouri Bar Association
Member
Member
Member
Valerie Patton
Delta Sigma Theta Sorority, Inc.
Howard University Alumni Club of St. Louis
National Association of Social Workers
St. Louis Gateway Classic Sports Foundation
The Links Incorporated
United Way of Greater St. Louis
Member
Member
Member
Board Member
Member, Treasurer
Board Member,
Member, Audit
Committee, Member,
Organizational
Development
Committee, Member,
CEO Search Committee
Board Member
University of Missouri-St. Louis - College of Business
Administration
Washington University in St. Louis - Alumni Board of
Governors
Betsy Schubert
Institute for Supply Management
Board Member
Member
Timothy R. Snoke
Institute of Management Accountants
St. John's Lutheran Church
St. John's Lutheran School Board of Education
St. Louis Treasury Management Association
Member
Member
Chair
Member
Jonathon Sprague
American Public Works Association (APWA)
American Water Works Association (AWWA)
Engineers Club of St. Louis
Missouri Water Environment
National Association of Clean Water Agencies (NACWA)
Water Environment Federation
Member
Member
Member
Member
Member
Member
Page 7 of 33
rev. 6/17/15
Vicki Taylor-Edwards
AAIM Management Association
Certified Employee Benefits Association
Compensation Benefits Network
Human Resources Management Association
International Public Management Association
Member
Member
Member
Member
Member
Rich L. Unverferth
American Society of Civil Engineers
Engineers Club of St. Louis
Knights of Columbus - Council 2119 Webster Groves
National Association of Clean Water Agencies (NACWA)
Member
Member
Member
Member
Michael E. Yates
North County Labor Legislative Club
St. Louis Labor Council
Executive Board
Member
Delegate
American Water Works Association
Government Finance Officers Association
National Association of Female Executives
National Association of Professional Women
Women in Public Finance
Member
Member
Member
Member
Member
Jan Zimmerman
Page 8 of 33
rev. 6/17/15
APPLICATION FOR CERTIFICATE OF QUALIFICATION TO BID
The undersigned hereby applies to the Metropolitan St. Louis Sewer District for a Certificate of Qualification to bid the
following types of work: (Check each type of work for which qualification is requested)
________ Sewer Construction
Section V. A., Page 12. Drain layers license required for City or County. Sewer Construction shall consist
of sewer projects requiring excavation of approximately 20 feet or less in depth and which do not require
significant involvement with urban type features such as utilities, structures, urban landscape, other features
of an urban nature, or significant amounts of classified excavation.
________
Deep Sewer Construction
Section V. B., Page 13. Drain layers license required for City or County. Deep Sewer Construction shall
consist of sewer projects requiring excavation of greater than approximately 20 feet in depth and/or that
requires significant involvement with trench bracing or urban type features, or significant amounts of
classified excavation. The District shall be the sole judge as to the type of construction each project falls
under.
________
Building Construction
Section V. C., Page 14
________
Natural Channel Stabilization
Section V. D., Page 15
________
Green Infrastructure and Bio-Retention
Section V. E., Page 16
________
Pipe and Manhole Rehabilitation
Section V. F., Page 17
Cured-In-Place Pipe (CIPP)
Section V. G, Page 18 & 19
Cured-In-Place Lateral Liner (CIPL)
Section V. H, Page 20 & 21
________
Concrete Channels, Walls and Structures
Section V. I., Page 22
________
Mechanical/Electrical/Plumbing
Section V. J., Page 23
________
Tunneling / Trenchless
Section V. K., Page 24
________
Demolition
Section V. L., Page 25 – Refer to page 25 for explanation of Class I & II
________
________
________
St. Louis County Demolition
St. Louis City – Class I and II
St. Louis City – Class II only
TYPE OF ORGANIZATION (Check Applicable Category)
______ Corporation ______ Partnership ______ Sole Proprietorship ______ Joint Venture
Firm Name: ________________________________Firm Address: ________________________
By ___________________________________
Title _________________________
_________________________________
(Signature)
Page 9 of 33
rev. 6/17/15
THE SIGNATORY OF THIS QUESTIONNAIRE GUARANTEES
THE TRUTH AND ACCURACY OF ALL STATEMENTS AND OF
ALL ANSWERS TO INTERROGATORIES HEREINAFTER MADE
Please list any previous experience or projects your company has completed for each category
you are requesting approval for, and any references you can provide. Attach additional sheets if
necessary.
Name of Contractor
_____________________________________________________
Principal Address
_______________________________________________________
(
(
(
(
(
(
)
)
)
)
)
)
A corporation
A general co-partnership
A limited co-partnership
An individual
Joint Venture
MWBE (Minority or Woman Business Enterprise)
If MWBE, what is the name of the agency/organization that issued the certification
document?
_______________________________________________________________
Please attach a copy of your certification document to this application.
Incorporated or organized:
Date _______________________ State ______________________________________
Radius of operations: ______________________________________________________
Type of work done:
______________________________________________________
Work usually sublet:
Name of Bonding Company _______________________________________________
Total Bonding Capacity of Firm $__________________________________________
I. How many years have you operated under the above name:
(a) As general contractor _____________________________________________
(b) As subcontractor ______________________________________________
II. List other names under which you have operated:
Name of company
_____________________________________________
Type of work done
______________________________________________
Operated during period
______________________________________________
Name of company
______________________________________________
Type of work done
______________________________________________
Operated during period
_____________________________________________
Page 10 of 33
rev. 6/17/15
III.
List of all partners or officers: (Note: if partnership limited, explain and please list
full 100% ownership)
Name and title_________________________________________________
Address, City and State____________________________________________
Fractional interest in firm or number of shares owned______________________
Name and title____________________________________________________
Address, City and State____________________________________________
Fractional interest in firm or number of shares owned ______________________
Name and title ___________________________________________________
Address, City and State____________________________________________
Fractional interest in firm or number of shares owned ______________________
IV.
What is the construction experience of the principal individuals of your
organization? (This includes the job superintendent).
An individual’s name
Present position or office
Years of construction experience
Magnitude and type of work
An individual’s name
Present position or office
Years of construction experience
Magnitude and type of work
An individual’s name
Present position or office
Years of construction experience
Magnitude and type of work
Page 11 of 33
rev. 6/17/15
V. List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION A. - Sewer Construction (See definition on page 9)
(Includes storm sewer, sanitary sewers, and small pump stations)
1. Contract Amount __________________
When Completed or Percent Complete__________________
Type of Project______________________________________________________
Pipe size and length laid______________________________________________
Location of Project
Name, Address & Phone
Number of Owner _________________________________________________
2. Contract Amount _________________
When Completed or Percent Complete __________________
Type of Project______________________________________________________
Pipe size and length laid______________________________________________
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner
________________________________________________
3. Contract Amount __________________
When Completed or Percent Complete __________________
Type of Project______________________________________________________
Pipe size and length laid______________________________________________
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
4. Contract Amount _________________
When Completed or Percent Complete ___________________
Type of Project_______________________________________________________
Pipe size and length laid______________________________________________
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
Page 12 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION B. - Deep Sewer Construction (See definition Page 9)
(Includes sanitary sewer, storm sewer, and small pump stations)
1. Contract Amount ____________________
When Completed or Percent Complete____________________
Type of Project______________________________________________________
Pipe size, average depth and length laid_________________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
2. Contract Amount ____________________
When Completed or Percent Complete ________________
Type of Project_______________________________________________________
Pipe size, average depth and length laid
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
3. Contract Amount _______________
When Completed or Percent Complete
__________
Type of Project______________________________________________________
Pipe size, average depth and length laid
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner
________________________________________________
4.
Contract Amount ____________________
When Completed or Percent Complete ________________
Type of Project______________________________________________________
Pipe size, average depth and length laid
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
Page 13 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION C - Building Construction
(Includes large pump stations, treatment plants, and operational facilities)
1. Contract Amount ________________________________________________
When Completed or Percent Complete_________________________________
Type of Project
____________________________________________________
Location of Project __________________________________________________
Name, Address & Phone
Number of Owner ___________________________________________________
2. Contract Amount __________________
When Completed or Percent Complete ___________________
Type of Project
___________________________________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner____________________________________________________
3. Contract Amount __________________
When Completed or Percent Complete __________________
Type of Project
___________________________________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner____________________________________________________
4. Contract Amount __________________
When Completed or Percent Complete ___________________
Type of Project
___________________________________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner___________________________________________________
Page 14 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION D. Natural Channel Stabilization:
1. Contract Amount _____________ When Completed or Percent Complete
Type of Project
_____________________________________________________
Specify channel stabilization methods installed: ______________________________
Location of Project
__________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
2. Contract Amount _____________When Completed or Percent Complete _______________
Type of Project______________________________________________________
Specify channel stabilization methods installed: ______________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner___________________________________________________
3. Contract Amount ______________When Completed or Percent Complete ______________
Type of Project
____________________________________________________
Specify channel stabilization methods installed: ______________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner
4. Contract Amount ______________When Completed or Percent Complete ____________
Type of Project
___________________________________________________
Specify channel stabilization methods installed: ______________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner___________________________________________________
Page 15 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION E. Green Infrastructure and Bio-Retention
1. Contract Amount ____________When Completed or Percent Complete
Type of Project
____________________________________________________
Specify green infrastructure methods installed______________________________
Location of Project
_________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
2. Contract Amount _______________When Completed or Percent Complete _____________
Type of Project______________________________________________________
Specify green infrastructure methods installed______________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner___________________________________________________
3. Contract Amount _______________ When Completed or Percent Complete _____________
Type of Project
____________________________________________________
Specify green infrastructure methods installed______________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner
4. Contract Amount _______________When Completed or Percent Complete _____________
Type of Project
___________________________________________________
Specify green infrastructure methods installed______________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner___________________________________________________
Page 16 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION F. - Pipe and Manhole Rehabilitation (Give pipe sizes)
(Includes point repair, pipe bursting, slip lining, etc.)
1. Contract Amount ________________
When Completed or Percent Complete
Type of Project
__________________________________________________
Location of Project___________________________________________________
Name, Address & Phone
Number of Owner___________________________________________________
2. Contract Amount _________________
When Completed or Percent Complete ____________________
Type of Project_______________________________________________________
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner____________________________________________________
3. Contract Amount ____________________
When Completed or Percent Complete _________________
Type of Project
____________________________________________________
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner
4. Contract Amount ____________________
When Completed or Percent Complete _________________
Type of Project ____________________________________________________
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner____________________________________________________
Page 17 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION G. – Cured-in-Place Pipe (CIPP)
Statement of Qualifications for Cured-in-Place Pipe
1.Project Name: _______________________________________________________
Contract Amount __________ When Completed or Percent Complete
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Installed Pipe Length: _____
Pipe Sizes: _____
Pipe Type: Gravity ____ Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________ Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
2. Project Name: __________________________________________________
Contract Amount ___________ When Completed or Percent Complete
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Length of Pipe Installed: _______ Pipe Size: _____________
Pipe Type: Gravity _______
Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________
Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
Page 18 of 33
rev. 6/17/15
SECTION G. – Cured-in-Place Pipe (CIPP)
Statement of Qualifications for Cured-in-Place Pipe
3.Project Name: __________________________________________________
Contract Amount ___________ When Completed or Percent Complete
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Length of Pipe Installed: _______ Pipe Size: _____________
Pipe Type: Gravity _______
Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________
Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
4. Project Name: __________________________________________________
Contract Amount___________ When Completed or Percent Complete
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Length of Pipe Installed: _______ Pipe Size: _____________
Pipe Type: Gravity _______
Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________
Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
Page 19 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION H. – Cured in Place Lateral Lining (CIPL)
Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral
connection repairs).
1.Project Name: _______________________________________________________
Contract Amount ___________ When Completed or Percent Complete
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an
approved installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________
Flexural Modulus __________________
2.Project Name: _______________________________________________________
Contract Amount ___________ When Completed or Percent Complete
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an
approved installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________
Flexural Modulus __________________
Page 20 of 33
rev. 6/17/15
SECTION H. – Cured in Place Lateral Lining (CIPL)
Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral
connection repairs).
3.Project Name: _______________________________________________________
Contract Amount __________ When Completed or Percent Complete
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an
approved installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________
Flexural Modulus __________________
4.Project Name: _______________________________________________________
Contract Amount __________ When Completed or Percent Complete
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an
approved installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________
Flexural Modulus __________________
Page 21 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION I. - Concrete Channels, Walls & Structures
1. Contract Amount ________________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project ________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
2. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
3. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
4. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
Page 22 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION J. - Mechanical/Electrical/Plumbing
1. Contract Amount ______________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
2. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
3. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
4. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
Page 23 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION K. – Tunneling / Trenchless
1. Contract Amount ______________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project ________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
2. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
3. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
4. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
Page 24 of 33
rev. 6/17/15
List all experience for the past five years in the categories for which you want to qualify.
List projects that are completed or in progress, attach additional sheets if necessary.
SECTION L. – Demolition
Demolition work for MSD within the City of St. Louis – attach certification for specific
classification. Class I–no building size restrictions. .Class II -limited to buildings under
3
stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. .Buildings under 1 ½
stories/10,000 cubic feet volume, with no basement, require no demolition license.
St. Louis County – does not require license.
1. Contract Amount ______________
When Completed or Percent Complete ________________________
Type of Project ______________________________________________________
Location of Project ________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
2. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
3. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
4. Contract Amount ________________
When Completed or Percent Complete ________________________
Type of Project_______________________________________________________
Location of Project_________________________________________________
Name, Address & Phone
Number of Owner_____________________________________________________
Page 25 of 33
rev. 6/17/15
EQUIPMENT
(What equipment do you own that is available for proposed work?)
QUANTITY
ITEM
DESCRIPTION, SIZE,
CAPACITY, ETC
EQUIP
HOURS
CONDITION
YEARS
OF
SERVICE
* Condition shall be graded as follows:
New under 12 months
N-1
Over 12 months old
0-1 (Good)
0-2 (Average)
0-3 (Fair)
0-4 (Poor)
Page 26 of 33
Rebuilt
R-1
R-2
R-3
R-4 (Poor)
rev. 6/17/15
PRESENT
LOCATION
SAMPLE INSURANCE REQUIREMENTS:
The following section supplements the provisions of Part 1, Section F, paragraph 8 of the
Standard Construction Specifications (2009).
Within fifteen (15) days after written notification by the District that the bid has been accepted
and receipt of the contract for signature, the successful bidder must provide five (5) copies of
executed Certificates of Insurance on ISO ACORD 25 forms with the District, indicating that the
bidder has obtained and will continue to carry commercial general liability, pollution liability,
workers compensation and business auto liability as required.
The successful bidder shall carry and maintain adequate commercial general liability insurance
for bodily injury, personal injury and property damage with a company satisfactory to the
District and which is:
 Licensed to do business in the State of Missouri (Admitted) with a financial strength rating of
“A-” or better and a financial size category of Class VI or higher per AM Best Company; or
 Not licensed in the State of Missouri (Non-admitted) with a financial strength rating of “A”
or better and a financial size category of Class IX or higher per AM Best Company; or
 For workers compensation coverage only, organized pursuant to the Missouri Insurance
Company Act (R.S.Mo §§ 287.900 to 287.920).
The insurance carrier will be acceptable regardless of the above requirements if the insurance
company furnishes a bond guarantee or policy containing a provision (commonly referred to as a
“cut-thru” endorsement) giving all claimants thereunder a direct right of recovery against the
company’s reinsurer, provided the reinsurer meets one of the qualifications listed above.
The amounts of coverage required herein shall not be construed to limit the liability of the
successful bidder under the indemnification provision of the contract.
The District (including its Trustees, officers, agents and employees) shall be named as
“Additional Insured(s)” for all required insurance coverage (with the exception of claims made
pollution liability and workers compensation coverage) with respect to the project. The
successful bidder shall require that any sub-contractor name the District and the successful
bidder as “Additional Insured(s)”. The additional insured endorsement(s) must be sufficiently
broad to afford the District coverage as required by the indemnification provision of the contract
and must include products and completed operations coverage included within the commercial
general liability policy.
COMMERCIAL GENERAL LIABILITY
Policy must include primary and non-contributory endorsement as to comply with CG 20 01 04
13 Primary and noncontributory other insurance condition.
The Commercial General Liability (CGL) policy shall include the following:
1. Premises – Operations Liability
2. Blanket Contractual Liability
3. Completed Operations Liability
4. Contractor’s Protective Liability (Independent Contractors)
5. Personal Injury Liability
Page 27 of 33
rev. 6/17/15
6. Broad Form Property Damage Liability Endorsement
7. Coverage for explosion, collapse and underground hazards (XCU)
8. Blasting (provided that blasting coverage may be excluded if not to be performed in
connection with the work)
A specific endorsement may be needed if non-standard coverage is provided.
Required Limits of Liability
$1,000,000
per occurrence
$1,000,000
Products and Completed Operations Aggregate
$1,000,000
Personal and Advertising Injury
$1,000,000
General Aggregate per project
-and$5,000,000
Excess (Umbrella)1
1
Limits of Excess (Umbrella) coverage for Construction Contracts less than $100,000 may be
reduced to $2,000,000.
POLLUTION LIABILITY
For contracts in excess of $100,000, the successful bidder shall maintain in force for the full
period of the Contract, pollution liability insurance coverage for losses caused by sudden and
non-sudden pollution conditions that arise from the operations of the successful bidder. Such
insurance shall apply to bodily injury and property damage, including loss of use of the damaged
property or property that has not been physically injured, and shall cover cleanup, and defense
costs, including all expenses incurred in the investigation, defense, payment or settlement of
claims.
Pollution Liability Limits:
$2,000,000
per claim or per occurrence
If pollution liability insurance is provided on a claims-made basis, the successful bidder shall
maintain the insurance in force of the full period of the contract and two years after completion
of the project.
BUSINESS AUTOMOBILE LIABILITY:
Insurance shall apply to all owned, non-owned and hired vehicles.
$1,000,000
Liability Coverage each occurrence
-and$5,000,000
Excess (Umbrella) Limits of Excess (Umbrella) coverage for Construction
Contracts less than $100,000 may be reduced to $2,000,000.
Page 28 of 33
rev. 6/17/15
WORKERS COMPENSATION INSURANCE:
Successful bidder shall provide proof of Workers Compensation Insurance with Statutory Limits,
to include Federal Acts and US Longshore & Harbor Workers Act (USL&H) coverage as
applicable.
Coverage shall also include Employers Liability with the following limits:
$500,000
each accident
$500,000
Disease Each Employee
$500,000
Coverage Limit
Excess Liability of $5,000,000 to include Employers Liability.
3
Limits of Excess (Umbrella) coverage for Construction Contracts less than $100,000 may be
reduced to $2,000,000.
DEDUCTIBLE/SELF-INSURED RETENTION:
For any coverage, a deductible or retention that exceeds $ 50,000 shall be noted and approved by
the District’s Risk Management Group. The District will reserve the right to review the funding
for a deductible or retention program. Satisfaction of any such deductible or retention shall be the
sole responsibility of the successful bidder.
CANCELLATION:
Cancellation provisions within any coverage shall be in accordance with Missouri Cancellation
and Non-Renewal provisions. It is the duty of the contractor to notify the District of any
cancellation or non-renewal and provide the District 60 days’ notice.
REPLACEMENT POLICY:
Should any of the required insurance coverage be cancelled, terminated or materially altered, the
successful bidder will send written notice to MSD at least sixty (60) days prior to the effective
date of said cancellation, termination or alteration. Upon receipt of any notice of insurance
cancellation, termination or alteration, the successful bidder shall within thirty (30) days procure
other policies of insurance identical in all respects to the policy or policies about to be canceled,
terminated or altered and shall provide the District with evidence of coverage before the
cancellation or termination date; and if the successful bidder fails to provide, procure and deliver
acceptable policies of insurance and satisfactory certificates or other evidence thereof, the
District may obtain such insurance at the cost and expense of the successful bidder without
notice to the successful bidder, and elect to pursue any other remedy permitted by law or the
contract terms, including but not limited to termination of the contract.
Page 29 of 33
rev. 6/17/15
Metropolitan St. Louis
Sewer District
2350 Market Street
St. Louis, Missouri 63103
RE: Insurance Requirements for Annual Pre-Qualification
Metropolitan St Louis Sewer District (MSD) requires contractors to be prequalified prior to
bidding on Capital Improvement Projects. In the prequalification process, contractors must
demonstrate their ability to perform in the event they are awarded a contract, including meeting
the District’s insurance requirements.
MSD has certain contract requirements relating to contractor insurance coverage, including
increasing the limits for certain coverage and requiring pollution liability coverage. The District
recognizes that these additional coverage requirements impose additional costs upon contractors.
In an effort to alleviate any short term burden on contractors, for pre-qualification and bid
purposes only, MSD is willing to accept a letter signed by both the contractor and the
contractor’s insurance broker stating that the contractor has been approved for the additional
insurance coverage and that the contractor will obtain all required coverage and with the limits
required in the event a contract is awarded to the contractor. Further, the letter must state
affirmatively that the policy will be endorsed and coverage will be in place in the event a
contract is awarded. Additionally, the letter must state that in the event a contract is awarded and
insurance is not secured within the required timeframe, the contractor will forfeit its bid bond on
the project and will be determined non-responsive. These affirmative representations must be
repeated as part of any bid submitted by a contractor that does not have the required coverage in
place at the time of the bid.
Thank you for your cooperation in this matter.
Sincerely,
Betsy Schubert
Purchasing Manager
Page 30 of 33
rev. 6/17/15
AFFIDAVIT FOR INDIVIDUAL
State of ____________________)
) ss.
County of __________________ )
___________________________________________, being duly sworn, deposes and says that
the answers to the foregoing interrogatories are true, and that any depository, vendor or other
agency herein named is authorized to supply The Metropolitan St. Louis Sewer District with any
information necessary to verify this statement.
__________________________________
(Applicant sign here)
Sworn to before me, this
_______________ day of ____________________, 20 _____.
_____________________________
Notary Public
(seal)
Page 31 of 33
rev. 6/17/15
AFFIDAVIT FOR CO-PARTNERSHIP
State of _____________________)
) ss.
County of ___________________)
___________________________________, being duly sworn, deposes and says that they are a
member of the firm of ___________________________________ that they are familiar with the
books of said firm showing its financial condition; and that the answers to the foregoing
interrogatories are true, and that any depository, vendor or other agency herein named is
authorized to supply The Metropolitan St. Louis Sewer District with any information necessary
to verify this statement.
________________________________
________________________________
_
________________________________
(Members of firm, sign above)
Sworn to before me, this _______________ day of ____________________, 20____.
_____________________________
Notary Public
Page 32 of 33
rev. 6/17/15
(seal)
AFFIDAVIT FOR CORPORATION
State of ______________________)
) ss.
County of ____________________ )
________________________________, being duly sworn, deposes and says that ___he is
___________________________________________________________of the
_______________________________________________________________________
the corporation described in and which executed the foregoing statement that he is familiar with
the books of the said corporation, showing its financial condition; and that the answers of the
foregoing interrogatories are true, and that any depository, vendor or other agency herein named
is authorized to supply The Metropolitan St. Louis Sewer District with any information
necessary to verify this statement.
________________________________
________________________________
Title
_______________________________
_______________________________
Title
Sworn to before me, this _______________ day of __________________, 20 _______.
_______________________________
Notary Public
(seal)
Page 33 of 33
rev. 6/17/15