Contractor Form

TO BE COMPLETED BY THE CONTRACTOR

Company Name *

Company Number *

Company Address *

Tel Number *

Email *

Contact Information

Main Contact Name *

Main Contact Number *

Email *

Submissions Contact Name *

Submissions Contact Number *

Submissions Contact Email *

Accounts Contact Name *

Accounts Contact Number *

Accounts Contact Email *

First Name *

Technical Monitoring Number *

Technical Monitoring Email *

Insurance Information

Professional Indemnity Insurance (£250,000 min) - Cover *

Professional Indemnity - Renewal date *

Employers Liability Insurance (£10m min) - Cover *

Employers Liability - Renewal date *

Public Liability Insurance (£5m min) - Cover *

Public Liability - Renewal date *

PLEASE ATTACH COPIES OF INSURANCE CERTIFICATES

No Choosen File

(Max 2 MB)

Company Details

Total number of employees in the Company *

Do you have memberships to relevant trade bodies? (e.g. NICEIC, Gas Safe, MCS and PAS) *

Yes

Do you operate certified management system(s)? (e.g. ISO9001, ISO45001, ISO14001, CHAS, Safe contractor) *

Yes

Name of person responsible for maintaining the management system(s) and qualifications *

Name of person responsible for maintaining health and safety in your company (provide contact details) *

If the person is a third party (consultant) provide details including CV

Yes

Measures Information

Measure Name

Trustmark Number

MCS Number

PAS ID Number

Your Title Here

Boiler Installations – C1

Heating Control – C5

NVQ Qualifications

Provide NVQs relevant to measures you install under ECO (Required with or without PAS):

Loft / Cold roof Insulation NVQ

Underfloor Insulation NVQ

Decision Box

Cavity wall Insulation NVQ

Internal wall Insulation NVQ

External wall insulation NVQ

Do you have financial protection for your customers?

Yes

Insurance backed guarantees (Qualitymark protection, HIES or RECC) *

Yes

Health and Safety

Provide details of health and safety training for operatives in your company

Which access pass would you like to purchase?

Yes

When was the H&S policy reviewed? *

Do you have risk assessment for all PAS and MCS measures? *

Yes

Do you have method statements for work activities?

Yes

Have you any improvement or prohibition notices from any enforcing body (HSE, Env), include past and pending? *

Yes

Have you ever been prosecuted for breaches of health and safety legislation?

Yes

Do you have any health and safety awards?

Yes

How do you consult with employees on health and safety issues? *

What is your procedure for reporting/investigating incidents? *

Who is responsible for dealing with any accidents/incidents in your company? *

Where RIDDOR reportable incidents have occurred provide summary of incident (no names)

Will you be using Subcontractors?

Yes

How are your subcontractors approved? *

Environmental. Do you ensure?:

Where practical, materials are sourced from sustainable sources?

N/A

Yes

All waste is removed from your work area?

N/A

Yes

Where practical, all waste is recycled?

N/A

Yes

Waste is segregated to promote recycling?

N/A

Yes

Please provide evidence of your upper waste carriers licence *

No Choosen File

(Max 2 MB)

Declarations (Mandatory completion)

Please answer Y (yes) / N (no) in the right-hand column. Where the response is Y provide additional information separately. This will be forwarded to the Head of Finance or other independent / impartial senior person within Bloxt Limited for review.

All the questions refer to the company (or its directors or any other person who has powers of representation, decision or control of the company).

Has the company been convicted of any of the following offences:

Mandatory Grounds

Conspiracy within the meaning of section 1 of the Criminal Law Act 1977 where that conspiracy relates to participation in a criminal organization as defined in Article 2(1) of Council Joint Action 98/733/JHA

Yes

Corruption within the meaning of section 1 of the Public Bodies Corrupt Practices Act 1889 or section 1 of the Prevention of Corruption Act 1906

Yes

The Offence of Bribery or Fraud

Where the offence relates to fraud affecting the financial interests of the European Communities as defined by Article 1 of the Convention relating to the protection of the financial interests of the European Union, within the meaning of:

Yes

the offence of cheating the Revenue
the offence of conspiracy to defraud.
fraud or theft within the meaning of the Theft Act 1968 and the Theft Act 1978
fraudulent trading within the meaning of section 458 of the Companies Act 1985
defrauding the Customs within the meaning of the Customs and Excise Management Act 1979 and the Value Added Tax Act 1994
an offence in connection with taxation in the European Community within the meaning of section 71 of the Criminal Justice Act 1993
destroying defacing or concealing of documents or procuring the extension of a valuable security within the meaning of section 20 of the Theft Act 1968
Money laundering within the meaning of the Money Laundering Regulations 2003

Any other offence within the meaning of Article 45(1) of the Public Sector Directive.

Yes

Discretionary Grounds

Being an individual he is bankrupt or has had a receiving order or administration order or bankruptcy restrictions order made against him or has made any composition or arrangement with or for the benefit of his creditors or has made any conveyance or assignment for the benefit of his creditors or appears unable to pay or to have no reasonable prospect of being able to pay, a debt within the meaning of section 268 of the Insolvency Act 1986, or article 242 of the Insolvency (Northern Ireland) Order 1989, or in Scotland has granted a trust deed for creditors or become otherwise apparently insolvent, or is the subject of a petition presented for sequestration of his estate, or is the subject of any similar procedure under the law Yes No

Yes

Being a partnership constituted under Scots law has granted a trust deed or become otherwise apparently insolvent, or is the subject of a petition presented for sequestration of its estate

Yes

Being a company or any other entity within the meaning of section 255 of the Enterprise Act 2002 has passed a resolution or is the subject of an order by the court for the company's winding up otherwise than for the purpose of bona fide reconstruction or amalgamation, or has had a receiver, manager or administrator on behalf of a creditor appointed in respect of the company's business or any part thereof or is the subject of the above procedures or is the subject of similar procedures under the law of any other state

Yes

Has been convicted of a criminal offence relating to the conduct of their business or profession

Yes

Has committed an act of grave misconduct during their business or profession

Yes

Any other offence within the meaning of Article 45(1) of the Public Sector Directive.

Yes

Has not fulfilled obligations relating to the payment of social security contributions under the law of any part of the United Kingdom or of the relevant State in which the Applicant is established

Yes

Option 3

Is guilty of serious misrepresentation in providing any information required by this document

Yes

In relation to procedures for the award of a public services contract, is not licensed in the relevant State in which he is established or is not a member of an organization in that relevant State when the law of that relevant State prohibits the provision of the services to be provided under the contract by a person who is not so licensed or who is not such a member

Yes

Where applicable, it is not registered with the appropriate trade or professional register(s) of the relevant State where it is established under the conditions laid down by that State.

Yes

The declarations have been reviewed and answered by:

Name

Position

Signed

Financial

To enable payment, please complete the information below:

To avoid any delays or queries being incurred.

Please be advised handwritten invoices could cause difficulty in processing. It is preferred that you submit invoices to us in an electronic format.

Please Provide a Bank Statement/Proof of Address

No Choosen File

(Max 2 MB)

ComapnyName

Address

Post Code

Contact Name (Financial)

Contact Number

Bank

Account Name

Branch

Account Number

Sort Code

VAT Number (If Applicable)

UTR (Unique Reference Number)

I agree to the Terms and Conditions

Type To Search

Type To Search

Type To Search

Our Gallery

Our Contacts

TO BE COMPLETED BY THE CONTRACTOR

Contact Information

Insurance Information

Company Details

Measures Information

Measure Name

Trustmark Number

MCS Number

PAS ID Number

Your Title Here

NVQ Qualifications

Provide NVQs relevant to measures you install under ECO (Required with or without PAS):

Health and Safety

Provide details of health and safety training for operatives in your company

Environmental. Do you ensure?:

Declarations (Mandatory completion)

Mandatory Grounds

The Offence of Bribery or Fraud

Discretionary Grounds

The declarations have been reviewed and answered by:

Financial

Our Rates:

Swi Under 750 - £23.00

GBIS: £22.50

Non-Solid - £12.00

Call us: 0800 0314395

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