Supplier Assessment Form

Company Details

Company Name:(Required)

Area of Expertise:

Invoice Address:(Required)

Address Line 1 Address Line 2 City County Postcode

Registered Address (if different to invoice address):

Address Line 1 Address Line 2 City County Postcode

Accounts Contact Name:(Required)

Accounts Phone Number:(Required)

Accounts Email:(Required)

VAT Number:

Website:

Type of Company:(Required)

Sole Trader

Limited Company

PLC

LLC

Registered Company Number(Required)

Details of key personnel/directors in company:(Required)

Full Name

Contact Number

Email Address

Has the company operated under any other name in the past five years?(Required)

Yes

No

If yes, give name(s):

Safety Record

In the past five years, has your company or any of its key personnel been investigated for or found to have committed a serious H&S violation?(Required)

Yes

No

If yes, provide details:

Do you have a written employee H&S policy and program?(Required)

Yes

No

Are there any open or aggregate liability claims that would impair your ability to insure any project?(Required)

Yes

No

If yes, provide details:

Insurance

Do you hold Employers Liability Insurance?(Required)

(please attach a copy)

Yes

No

Value of coverage:(Required)

Copy of Employers Liability Insurance(Required)

Drop files here or

Max. file size: 50 MB.

Do you hold Public Liability Insurance?(Required)

(please attach a copy)

Yes

No

Value of coverage:(Required)

Copy of Public Liability Insurance(Required)

Drop files here or

Max. file size: 50 MB.

Other Information

Has your company or any of its personnel been a party to a bankruptcy or reorganisation proceeding?(Required)

Yes

No

If yes, give date:

During the past five years, have any liens been filed against you by any of your subcontractors or suppliers?(Required)

Yes

No

If yes, give details:

Have you ever failed to complete a contract, been defaulted, or had a contract terminated?(Required)

Yes

No

If yes, give dates and details:

References

(Attach extra sheet if necessary)

Trade References(Required)

(List two of your subcontractors or suppliers)

Company Name

Full Name

Contact Number

Email Address

Client References(Required)

(List two clients, include name, email and phone number)

Company Name

Full Name

Contact Number

Email Address

SSIP Accreditation

(Attach Certificate from relevant body)

Do you hold a current Certificate from an SSIP Member?(Required)

Yes

No

If yes, name of organisation:

Expiry Date:

Copy of certificate

Max. file size: 50 MB.

ISO Accreditation

(Attach Certificate from relevant body)

ISO9001(Required)

Yes

No

ISO14001(Required)

Yes

No

ISO145001(Required)

Yes

No

File

Drop files here or

Max. file size: 50 MB.