Call: 01383 829546

Email: [email protected]

KDM Group Contractor Evaluation Form

KDM-OHS-IF-09
Please complete all fields on this form and ensure where prompted, you attach the requested information. Fields marked with a * are mandatory and therefore must be fully completed before the form is submitted. Thank you.

Type of Business?

Please Select *

Business Details

Business Name *

Registering Partners Name *

Operating Address *

Post Code

Telephone *

Mobile

Email Address *

Web Address

Registered Address *

Registered Address Postcode *

Company Registration No. *

Are you UK VAT Registered? *

UK VAT No. *

Are you Republic of Ireland VAT Registered? *

ROI VAT No. *

Are you registered for RCT in Republic of Ireland? *

RCT No. *

UK NI No. OR Republic of Ireland PPS No. *

UK UTR No. *

The registering partners UTR number *

Do you hold a current UK, Republic of Ireland or EU Driving Licence *

Driving license number *

Do you have UK CSCS card or for Republic of Ireland do you have a Solas CSCS, Safe Pass, CSR, CPCS or affiliated card which is relevant to your work activity? *

Enter your card number *

Do all partners have UK CSCS card or for Republic of Ireland do you have a Solas CSCS, Safe Pass, CSR, CPCS or affiliated card which is relevant to your work activity?

Enter card numbers *

CITB No.

Sorry if you do not have a CSCS Card Type and Number then you cannot submit an application.

Do you have SMSTS / SSSTS Accreditation? *

Date of Birth *

Next of Kin: Name and Contact Number *

Annual Turnover *

Bank Account Name *

Bank Name *

Bank Address *

UK Sort Code or Republic of Ireland BIC Code *

UK Account No. or Republic of Ireland IBAN No *

Upload file *

No file chosen

Attach copy of all bank details on your headed paper (Maximum file upload 20MB) Maximum file upload 20MB

Operations

Main Trade *

Other Trades

Minimum Order Value £ *

Maximum Order Value £ *

Do you provide design services?

Indicate Level of Service

Indicate level of service *

Do you operate on a national basis throughout the UK? *

If NO please indicate the areas you can operate(select multiple if required)

Do you operate in the Republic of Ireland? *

Are you resident in Republic of Ireland? *

Trading currency? *

How many direct employees do you have?

Managers *

Supervisors *

Skilled *

Unskilled *

How many subcontractors do you have?

Managers *

Supervisors *

Skilled *

Unskilled *

INSURANCE DETAILS

Do you hold the following insurance? *Please attach a copy of your current insurance certificates. Documents are to be verified by KDM prior to you being able to operate on site.

Public Liability Insurance *

Cover (£m) *

Expire Date *

Attach certificate (Maximum file upload 10MB) *

No file chosen

Employers Liability Insurance *

Cover (£m) *

Expire Date *

Attach certificate (Maximum file upload 10MB) *

No file chosen

Contractors 'All Risk' Insurance *

Cover (£m) *

Expire Date *

Attach certificate (Maximum file upload 10MB) *

No file chosen

Products Liability Insurance *

Cover (£m) *

Expire Date *

Attach certificate (Maximum file upload 10MB) *

No file chosen

Professional Indemnity Insurance *

Cover (£m) *

Expire Date *

Attach certificate (Maximum file upload 10MB) *

No file chosen

Scope of CIS

Please confirm if your works falls within the Scope of CIS? *

If “No” then we require a statement on headed paper advising why you are out with the scope of CIS Attach certificate (Maximum file upload 10MB) *

No file chosen

Health and Safety

Do you have a SSIP Certificate? *

SSIP Certificate (Maximum file upload 10MB)

No file chosen

Please supply if available a copy of your current SSIP (CHAS, Avetta, SAFE Contractor). KDM will look to engage subcontractors in the first instance who can verify SSIP accreditation.

Do you have a written health & safety policy? *

If no, please confirm if you employ less than 5 persons or if there are any other reasons please explain

If yes, please upload a copy signed by the director/senior manager responsible for health & safety (Maximum file upload 10MB) *

No file chosen

If yes please upload a copy of a document that outlines details of your organization, roles, and responsibilities for health & safety (Maximum file upload 10MB) *

No file chosen

If yes, please upload a copy of a document that outlines details of your general arrangements for health & safety (Maximum file upload 10MB) *

No file chosen

Do you have a written environmental policy? *

If yes, please upload a copy signed by the director/senior manager responsible for Environmental Management (Maximum file upload 10MB) *

No file chosen

If yes please upload a copy of a document that outlines details of your organization, roles, and responsibilities for Environmental Management (Maximum file upload 10MB) *

No file chosen

If yes, please upload a copy of a document that outlines details of your general arrangements for Environmental Management (Maximum file upload 10MB) *

No file chosen

Please provide details of who in your organisation is responsible for health & safety? Name, position & contact details *

Do you gain Health & Safety advice from an external source? *

Do you gain health & safety advice from an external source? If yes please confirm Company, name, position & contact details *

Company *

Name *

Position *

Phone *

Please confirm that all operatives who attend site will hold a current CSCS or affiliated card which is relevant to their work activity? *For Republic of Ireland please confirm they will hold Solas CSCS, Safe Pass, CSR, CPCS or affiliated card which is relevant to their work activity?

If yes, please upload copies. (Maximum file upload 10MB) *

No file chosen

Please confirm that, when applicable, all operatives on site will hold current asbestos awareness training. *

If yes, please upload copies. (Maximum file upload 10MB) *

No file chosen

Please confirm that you have recorded Toolbox Talks that have taken place within the last 6 months *

If yes, please upload copies. (Maximum file upload 10MB) *

No file chosen

Please confirm that you have provided Risk & Method Statements for works that have taken place within the last 6 months *

If yes, please upload copies. (Maximum file upload 10MB) *

No file chosen

Please confirm that you can provide Accident, Incident statistics to cover the last 3 years? *

Average # of persons employed - Last year *

Previous year *

Year before that *

Total # of recorded accidents & incidents - Last year *

Previous year *

Year before that *

Total # of recorded near miss incidents - Last year *

Previous year *

Year before that *

Total # of enforcement action served - Last year *

Previous year *

Year before that *

Company Name *

Name *

Position *

Telephone *

If employing more than 5 employees we require a copy of your health and safety policy

Copy attached (Maximum file upload 10MB)

RECOGNITION & COMPETENCE

Do you carry out in house/external training?

If so please attach details? (Maximum file upload 10MB)

Are you a member of any trade federations/accreditation, if so please list below?

Federation/Accreditation / Details / Date received / expiry

Declaration

I, the undersigned have read and agree to adhere to all KDM working policies and procedures and confirm that the information provided is accurate.

Signed by Name *

Signed by Position *

Sign by Date *

Disclaimer

*This document must be electronically signed by the Business Owner in the case of Sole Trader/Partnership or Director in the case of a Limited Company and forwarded by clicking on the Submit button below. Please note that failure to submit this document in full can delay any payments to your business.