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6.D. - Page 94 of 170 <br />Request for Qualifications: <br />General Park Building Construction, Retrofit, Maintenance, and/or Repairs <br />D. FINANCIAL RESOURCES AND RESPONSIBILITY <br />5. In the past five years, has your firm ever been denied bonding? <br />❑ Yes 9 No <br />If Yes, explain on Attachment B the circumstances surrounding each instance. <br />6. Is your firm now, or has it ever been at any time in the last five years, the debtor in a bankruptcy <br />case? <br />❑ Yes K No <br />If Yes, explain on Attachment B the circumstances surrounding each instance. <br />7. Is your company in the process of, or in negotiations toward, being sold? <br />❑ Yes ® No <br />If Yes, explain the circumstances on Attachment B. <br />E. INSURANCE <br />8. In the past five years, has any bonding company made any payments to satisfy any claims made against <br />a bond <br />issued on your firm's behalf? <br />❑ Yes R No <br />If Yes, explain the circumstances on Attachment B the circumstances surrounding each <br />instance. <br />9. Indicate whether your firm currently has a Workers' Compensation insurance policy in effect, whether it is <br />legally self-insured, or whether it currently has no Workers' Compensation insurance policy in effect. <br />Workers' Compensation Insurance Policy Currently in Effect <br />❑ Legally Self -Insured <br />❑ No Workers' Compensation Policy Currently in Effect <br />If you have no workers' compensation insurance policy currently in effect, and you are not legally self- <br />insured, provide an explanation on Attachment B. <br />10. List the Experience Modification Rate (EMR) issued to your firm annually by your Workers' Compensation <br />insurance carrier for the last three years. Begin with the most recent year (YR 1) that an EMR rate was <br />issued (EMR -1). If any of the rates for the three years is or was 1.00 or higher, you may provide an <br />explanation on Attachment B. <br />YR. 1:_201EMR-1:.51 YR 2:aOl5 EMR -2: •95 YR. 3:10IH EMR -3: <br />11.Within the past five years, has your firm ever had employees but was without Workers' Compensation <br />insurance or state approved self-insurance? <br />❑ Yes RNo <br />If Yes, explain on Attachment B the circumstances surrounding each instance. If No, attach a <br />statement from your Workers' Compensation insurance provider that you have been <br />continuously insured for the past five years. <br />Responsibility Questionnaire (Rev. 1/25/12) <br />IMPORTANT — RESPONDERS MUST SUBMIT ALL REQUIRED FORMS (COMPLETELY FILLED <br />OUT) BY RFQ SUBMITTAL DEADLINE. 177 <br />Page 88 of 103 <br />