P.O. BOX 4189, PASO ROBLES, CA 93447

PHONE: 805-238-3510

FAX: 805-238-1975

SUBCONTRACTOR PREQUALIFICATION QUESTIONNAIRE

All information submitted will be considered official information acquired in confidence and MGE Underground, Inc. will maintain its confidentiality to the extent permitted by law.

Instructions: Please fill out all information requested and return via email to prequal@mgeunderground.com or mail to MGE Underground Inc., PO Box 4189, Paso Robles, CA 93447 Attention: Subcontractor Prequalification.

(Name of license holder exactly as on file with the California State License Board)

1. CONTRACTOR INFORMATION

Contractor License Number and Classification(s)

Structure of Company (please check one and provide information accordingly):

How

many

___ CORPORATION Date of Incorporation: ____________________________________________ State of Incorporation: ____________________________________________ President Name: ________________________________________________ Vice-President's Name: ___________________________________________

years

has

your

Orga

nizati

on

been

in business as a Contractor? _______Years

How many years has your Organization been in business under its present business name? __________Years

Vice-President's Name: ___________________________________________ Secretary's Name: _______________________________________________ Treasurer's Name: _______________________________________________ ___ PARTNERSHIP Date of Organization: _____________________________________________ Name and Address of Principals (state whether general or limited partnership): ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ___ INDIVIDUAL If other than a Corporation or Partnership, describe organization and name of Principals: _____________________________________________________ ______________________________________________________________

Under what other entities or former names has your Organization operated?

List the type of work normally performed with your own forces:

Page 2 of 6

2. EXPERIENCE INFORMATION

Provide information for a few key projects either currently being performed or most recently completed.

Attach a list of management and key personnel to be assigned to the Project. Key staff to be committed on this Project must have experience in field and engineering coordination and managing work where contractor was acting in a similar role on a Project of similar scope and magnitude. The following information is requested for each project. Please copy the below information for additional projects if necessary.

Project Title: _______________________________________________________________________________

Location:__________________________ Project Description: ________________________________________ Location:__________________________ Project Description: ________________________________________

Project Owner Information: Name: ______________________________________________________________

Contact: ____________________________________Telephone: _____________________________________

Describe Your Work on the Project:

Total Construction Value: $_____________________________________Percent Complete:_____________%

If Your Work Was Performed As A Subcontractor: General Contractor Information:

Name: ______________________________________________ Contact: ____________________________

Telephone___________________________ Initial Subcontract Value: _________________________ Final

Subcontract Value: _________________

Name of Design Architect/Engineer:_________________________________________

Contact:______________________________________ Phone No.:___________________________

Address:__________________________________________________________________________

Dollar Amount Of Claims: Submitted $_____________________ Settled $_____________________________

3. FINANCIAL DATA 3. FINANCIAL DATA

Attach copies of your last three years financial statements (Income Statement, Balance Sheet and Cash Flow) and include the most recent interim financial statement (Income statement, Balance Sheet and Cash Flow).

Please provide any additional information not contained in the financial statement footnotes that would explain any unusual circumstances that may have impacted, either positively or negatively, the financial status of your firm during this period.

Please provide the amount of work currently on bahere as work the contractor has been ordered, awarded, or contracted to do but which has not yet started.

Current Total Project Backlog $___________________________________

Indicate the size of Project you are most competitive in performing. $_________________________________

Bank Reference. Provide bank reference, including contact person, address and phone number.

Bank:___________________________________________Branch:______________________________

Address:_____________________________________________________________________________

Telephone:______________________________________Contact:_______________________________ Telephone:______________________________________Contact:_______________________________

Other References. Provide list of owners, architects, engineers, suppliers and trade subcontractors, including contact person, address and phone number. (Minimum of two reference and maximum of 4)

4. SAFETY PERFORMANCE AND SAFETY PROGRAM

Name and contact information for your company Safety Manager:

___________________________________________________________________________________

Page 3 of 6

A) Experience Modification Rate (EMR): Please provide your company's experience modification rate (EMR) for the past three years and current year. Attach a letter from your insurance carrier or State Fund on their letterhead verifying the EMR data. In addition, please indicate if they are interstate or intrastate rates.

YEAR EMR INTER/INTRASTATE

Current

2012

2011

2010

B) Injury/Illness Data and Total Recordable Incident Rate 300 and 300A Logs and attach copies duly signed by an authorized person. If your company is not required to maintain an OSHA Log, please provide data for Items 1 5, and 7.

CRITERIA YTD 2013 2012 2011 2010

1. *Number of fatalities

2. Number of days away from work cases

3. Number of days away from work

4. Number of cases involving job transfer or restriction

5. Number of medical cases only

6. Total number of recordable injuries/illnesses 6. Total number of recordable injuries/illnesses

7. Total hours work by all employees

8. *TOTAL RECORDABLE INCIDENT RATE (TRIR)

(Item #6 multiplied by 200,000. Divide by item #7.)

9. *DAYS AWAY FROM WORK RATE* (DAFWR)

(Item #3 multiplied by 200,000. Divide by item #7.)

*KEY PERFORMANCE INDICATOR

Has your company received any OSHA (federal or state-equivalent) and/or EPA (federal or state-equivalent) citations, notices of violations, warning letters, etc. in the past five years? No ______ Yes ______ If yes, for what?________________________________________

Page 4 of 6

C) Safe Work Practices and Procedures: Please indicate the following safe work practices or procedures that your company has successfully implemented:

PRACTICES OR PROCEDURES YES NO NA

1. Behavior based safety program

2. Loss Prevention Observations

3. Procedures for incident investigations for losses and near losses

4. Safety inspections for workplace and equipment

5. Drug and alcohol policy and testing procedures (including DOT compliance) 5. Drug and alcohol policy and testing procedures (including DOT compliance)

6. Defensive driving

7. Short service employee

8. Health and safety training or certification that include the following at a minimum:

a. Crane Operation

b. Drilling

c. Electrical Safety

d. Emergency Response

e. Fall Protection (Working From Heights)

f. Fire Prevention and How to Use Fire Extinguishers

g. First Aid/CPR

h. Hand Safety

i. Hazard Communication (Right to Know)

j. Lockout Tagout

k. Materials Handling, Manual Lifting

l. OSHA 40 Hour HAZWOPER and 8 Hour Refresher

m. Permit Required Confined Space

n. Personal Protective Equipment

o. Power Actuated Tools

p. Rigging

q. Stop Work Authority

r. Welding, Cutting, or Brazing (Hot Work)

s. Working Near Overhead Power Lines

9. If required by 29 CFR 1910 or 1926, have personnel performing the work successfully completed 40 Hour HAZWOPER and 8 Hour HAZWOPER Refresher?

10. Are personnel that will be performing the work competent and have successfully 10. Are personnel that will be performing the work competent and have successfully completed training and/or certification specific to the tasks being performed and for the equipment or tools they will be using?

11.

12. Full time Health and Safety project management and leadership.

13. Do you provide onboarding orientations for new employees?

14. Do you conduct daily tailboard safety meetings?

15. Does your insurance company's loss control specialist visit the project site?

Page 5 of 6

PRACTICES OR PROCEDURES YES NO NA

16. Do you have home office safety representatives who visit/audit the job?

5. INSURANCE REQUIREMENTS

Attach evidence of coverage by a qualified Liability Insurer in at least the amounts shown below. This is the minimum insurance that the subcontractor will be required to procure and maintain for the duration of the project.

Commercial General Liability Commercial Auto Bodily Injury $ 10 Million per occurrence /10 Million Aggregate Bodily Injury $ 2 Million Combined Single Limit Property Damage $10 Million per occurrence /10 Million Aggregate Property Damage $ 2 Million Combined Single Limit Workers' Compensation $ Legal Limit

6. LITIGATION HISTORY

List any history of claims, litigation disputes, arbitration and/or termination for cause associated with any work contracted on any project in the past 5 years. If Contractor has no history of litigation, claims or disputes, please so state.

Have you ever had a contract terminated for default within the past 5 years? No _________ Yes _________ If yes, why and when:

Are there any judgments, claims, arbitration proceedings, or suits pending or outstanding against your organization? No ____________ Yes ____________ (If Yes, attach an explanation.)

Has your organization filed any law suits, requested arbitrations or been involved in any litigation with regard to your contract activity within the last five years? If not applicable, check No. No ____________ Yes ____________

Are any of the above with Pacific Gas & Electric? No ____________ Yes ____________

CERTIFICATION

If any portion of this questionnaire is found to have any intentionally misleading information or material discrepancies, the Contractor may be deemed disqualified. By my signature, I represent and certify that the information presented is true and correct to the best of my knowledge and that I am a Company Officer responsible for Completion of the questionnaire.

Signature ___________________________________________________________

Typed or Printed Name and Title _________________________________________

Address (for delivery of certified mail)_________________________________________

City, State, and Zip Code__________________________________________________

Telephone Number________________ Fax Number_________________________

Please place a check to indicate that you have attached the following documents to the completed Questionnaire: ___List of management and key personnel to be assigned to the project ___Financial statements for the last three years (Income Statement, Balance Sheet and Cash

Flow) and include the most recent interim financial statement (Income statement, Balance Sheet and Cash Flow).

___Last 3 years of OSHA logs ___Letter verifying EMR data ___Evidence of insurance coverage Please make sure to also provide certificates of insurance

showing MGE Underground, Inc. and PG&E as additional insureds ___Illness and Injury Prevention Program

Page 6 of 6

___Explanation regarding Litigation History (if applicable)