CRCA STANDARD FORM OF ROOFING CONTRACTORS
QUALIFICATION STATEMENT – At-Large Member
1. Roofing Contractor’s Name
Address
Telephone ( ) Fax ( )
Year of Incorporation Province of Incorporation
Please submit a copy of your incorporation documents.
2. Names and Titles of Contractor’s Officers, Partners, Individual Owner
(a)
(b)
(c)
3. Other Trade Affiliated Associations to which contractor belongs
(a)
(b)
(c)
4. Average annual number of employees
Roofers: Sheet metal workers: Journeymen:
5. (a) Do you sublet all or part of your roofing work? Yes or no (circle one)
(b) Do you sublet all or part of your sheet metal work? Yes or no (circle one)
If YES in either (a) or (b), please explain the reasons for doing so.
6. Do you own or lease your roofing equipment? Own or lease (circle one)
7. Union Affiliation and Local Number (if applicable)
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8. Approximate annual income of roofing work done in the past four (4) years
20 20 20 20
Roofing income $ $ $ $
Percentage of total income % % % %
9. Insurance information
Insurance company’s name
Agent’s name Tel. #
Policy # Liability coverage $ Liability deductible $
Does the insurance policy contain a hot work endorsement? Yes or no (circle one)
Please include a copy of the insurance policy certificate of coverage. It is recommended
that CRCA members carry a minimum of $5 million in liability coverage.
This information must be submitted annually to CRCA to maintain
your membership.
10. Financial references
(a) Bank
Telephone ( ) Contact
(b) Name of bonding or surety company
Telephone ( ) Contact
(c) Other financial or credit references
(i) Name of Agency
Telephone ( ) Contact
(ii) Name of Agency
Telephone ( ) Contact
(d) Has there been any legal proceeding against your company in the last 5 years?
Please explain:
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(d) Have you or any of your principles/partners within this company
declared bankruptcy within the last 10 years?
Please explain:
11. Occupational Health and Safety
(a) Are you a member in good standing with the Workers Compensation Board in your
province?
Yes or No (please circle one)
Please provide a current copy of your provincial WCB clearance certificate.
This information must be submitted annually to CRCA to
maintain your membership.
(b) Is your company COR (The Certificate of Recognition program) certified in your
province?
Yes or No (please circle one)
Please provide a current copy of your provincial COR certificate.
This information must be submitted annually to CRCA to
maintain your membership.
12. Business licence
Please submit a copy of your business licence which must be located in a commercially
zoned property or a property that can be lawfully used for commercial purposes.
13. Names and suppliers from whom you have purchased roofing materials in the
past eighteen (18) months
Tel. #
Tel. #
Tel. #
14. List three principal projects your company has completed in the past five (5) years
Please include the final completion inspection report for each project.
(i) Project Completion date
Roofing contract value $ Roofing system applied
New construction Re-roofing
Owner
Contact Telephone ( )
Architect/Engineer/Consultant _
Contact Telephone ( )
(ii) Project Completion date
Roofing contract value $ Roofing system applied
New construction Re-roofing
Owner
Contact Telephone ( )
Architect/Engineer/Consultant
Contact Telephone ( )
(iii) Project Completion date
Roofing contract value $ Roofing system applied
New construction Re-roofing
Owner
Contact Telephone ( )
Architect/Engineer/Consultant
Contact Telephone ( )
14. List principal projects your company has in progress
(i) Project
Roofing contract value $ Roofing system applied
New construction Re-roofing
Owner
Contact Telephone ( )
Architect/Engineer/Consultant
Contact Telephone ( )
(ii) Project
Roofing contract value $ Roofing system applied
New construction Re-roofing
Owner
Contact Telephone ( )
Architect/Engineer/Consultant
Contact Telephone ( )
(iii) Project
Roofing contract value $ Roofing system applied
New construction Re-roofing
Owner
Contact Telephone ( )
Architect/Engineer/Consultant
Contact Telephone ( )
15. I hereby advise that the information provided is true and correct to the best of
my knowledge
Firm Name
Signature
Title
Date
Please ensure that the Qualification Statement document is fully completed and includes the
documents listed below. An incomplete document will delay your application process.
o Insurance policy certificate of coverage
o Provincial WCB clearance certificate
o Provincial COR certificate
o A copy of your business licence
o The final completion inspection report for each project completed
