1.Company Legal Name & d/b/a if Applicable:

2.Your Name & Title:

3.Workers' compensation experience modifier (EMR) for 2022:

4.Workers' compensation experience modifier (EMR) for 2023:

5.Workers' compensation experience modifier (EMR) for 2024:

6.Number of OSHA Recordables in Past Three (3) Years:

7.MIOSHA Violations in Past Three (3) Years:

8.Does your company have a written, enforced safety program? If yes, please email to: compliances@horizonbuildinggroup.com

YesNo

9.Number of Office Employees:

10.Number of Field Employees:

11.Dollar Amount of Work Currently Under Contract:

12.Dollar Amount of Largest Contract in Company's History:

13.What divisions and scopes of work does your company perform?

14.Is your company currently, does your company expect to be, or has your company been part of litigation and/or arbitration/mediation in the past three (3) years? If yes, please explain.

15.GC/CM Reference #1 (company, contact person, contact info, job(s) completed):

16.GC/CM Reference #2 (company, contact person, contact info, job(s) completed):

17.GC/CM Reference #3 (company, contact person, contact info, job(s) completed):