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10. In the past five years, has your firm made any claim against a project owner concerning work on a
<br />project or payment for a contract, and filed that claim in court or arbitration? ❑ Yes ❑ No
<br />If "yes," on a separate page identify the claim(s) by providing the project name, date of the claim,
<br />name of the claimant, the name of the entity the claim was filed against, a brief description of the
<br />nature of the claim, the court and case number, and a brief description of the status of the claim
<br />(pending, or if resolved, a brief description of the resolution.)
<br />11. At any time during the past five years, has any surety company made any payments on your firm's
<br />behalf as a result of a default, to satisfy any claims made against a performance or payment bond
<br />issued on your firm's behalf in connection with a project, either public or private? ❑ Yes ❑ No
<br />12. In the last five years, has any insurance carrier, for any form of insurance, refused to renew an
<br />insurance policy for your firm? ❑ Yes ❑ No
<br />13. Has your firm or any of its owners, officers, or partners ever been liable in a civil suit, or found guilty
<br />in a criminal action, for making any false claim or material misrepresentation to any public agency
<br />or entity? ❑ Yes ❑ No
<br />14. Has your firm or any of its owners, officers or partners ever been convicted of a federal or state
<br />crime of fraud, theft, or any other act of dishonesty? ❑Yes ❑No
<br />If "yes," identify on a separate page, the person or persons convicted, the court case and number,
<br />the crimes and the year convicted.
<br />15. If your firm was required to pay a premium of more than one percent for a performance and
<br />payment bond on any project(s) on which your firm worked at any time during the last three years,
<br />state the percentage that your firm was required to pay. If you wish to do so, you may provide an
<br />explanation for a percentage rate higher than one percent. %
<br />16. During the last five years, has your firm ever been denied bond credit by a surety company, or has
<br />there ever been a period of time when your firm had no surety bond in place during a project when
<br />one was required? ❑ Yes ❑ No
<br />17. Has Cal -OSHA cited and assessed penalties against the contractor or its associates for any
<br />"serious," "willful" or "repeat" violations of its safety or health regulations in the past five years?
<br />❑ Yes ❑ No
<br />(Note: If you have filed an appeal of a citation, and the Occupational Safety and Health Appeals
<br />Board has not yet ruled on your appeal, you need not include information about it.)
<br />If 'yes," on a separate page describe the citations, the party against whom the citation was made,
<br />date of citation, nature of the violation, project on which the citation was issued, owner of the
<br />project, and the amount of penalty paid, if any. State the case number and the date of any OSHAB
<br />decision.
<br />18. Has the Federal Occupational Safety and Health Administration cited and assessed penalties
<br />against the contractor or its associates in the past five years? ❑ Yes ❑ No
<br />(Note: If an appeal of the citation has been filed and the Appeals Board has not yet ruled, or there
<br />is a court appeal pending, you need not include information about the citation.)
<br />If "yes," on a separate page describe the citation, the party against whom the citation was made,
<br />date of citation, nature of the violation, project on which the citation was issued, owner of project,
<br />and the amount of penalty paid, if any. State the case number and date of any decision.
<br />Page 142
<br />PD Janjtorial S01
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<br />FP 17-022
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