HEALTHY HOME REPAIR PROGRAMContractor Application

HEALTHY HOME REPAIR PROGRAM
Contractor Application

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Name of Company:

Your Name:

First Name

Last Name

Mailing Address:

City, State, Zip:

Business Phone Number:

Cell Phone Number:

Tax ID or Social Security Number:

City Business License Number and Year:

Do you have your State of Missouri Lead License?

YesNo

State of Missouri Lead License Number:

E-mail:

Owner's Name(s):

Years in Business:

Number of Employees:

Of those, how many are family members:

Description of Services Offered:

Previous companies owned by officers or owners:

DBE:

MBE:

WBE:

D/M/WBE Date:

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LICENSES

Please provide appropriate licenses to perform specialty trade work such as electrical, plumbing and HVAC. The contractor, shall at all times, during the life of the contract, comply with Worker's Compensation laws of the State of Missouri. Insurance must remain current while participating.

Employee's Name with License Address, Phone and License Number:

Additional Employee's Name with License Address, Phone and License Number:

REFERENCES

Please list the names and addresses of 3 locations where you've recently worked. Include name, address and telephone of each reference listed.

Reference One:

Name:

Address:

Phone Number:

Reference Two:

Name:

Address:

Phone Number:

Reference Three:

Name:

Address:

Phone Number:

CREDIT

List the name(s), address(es) and phone number(s) of your present supplier(s). Also provide the number of years you have done business, your highest credit limit and your present status with your supplier(s).

Supplier One:

Name:

Address & Phone:

Years of Credit:

Credit limit:

Supplier Two:

Name:

Address & Phone:

Years of Credit:

Credit limit:

Supplier Three:

Name:

Address & Phone:

Years of Credit:

Credit limit:

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I/We hereby certify that the foregoing figures and the statements contained herein, submitted to obtain approval for the HEALTHY HOME REPAIR PROGRAM (HHRP), are true and correct to the best of my/our knowledge and belief. I/We have provided the above information, and certified that it is true, and have fully authorized Mission: St. Louis to verify said information through credit reports, deposit verifications, reference checks and through an other means the determine necessary. I/We understand that approval does not guarantee work availability from the agency.

Updated insurance documentation must be supplied to the agency upon approval on an annual basis. I/We also understand that the HHRP agencies reserves the right to terminate approval based on documented poor performance, failure to pay suppliers, or failure to supply adequate insurance documentation or other applicable licenses. Furthermore, I/We agree to indemnify and hold the Healthy Home Repair Program and its partner agencies including Mission: St. Louis, Mission: St. Louis' Board of Directors, employees, volunteers, homeowners and visitors; Community Development Administration for the City of St. Louis, and the City of St Louis Building Division free and harmless from any and all liability for injury to or death of any person, or for damage of property arising from the use and construction inside the premises by contractor or from the act or omission of any person or persons.

Authorized Signature Contractor's Representative:

Date:

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Contractors— General Liability, Workers Compensation and Automobile Insurance Coverage is required by the Healthy Home Repair Program.

Comprehensive Public Liability Insurance: General Liability, for each occurrence, at least $300,000.00
Workers Compensation and Employers' Liability for at least $100,000.00; (no exceptions)
Automobile Insurance for the contractor's vehicles on the job site shall be full Coverage;
Certificate of Liability Insurance for General Liability, Workers Compensation and Automobile Liability for 3 different Certificate Holders:

HHRP/Mission: St. Louis - 3108 N Grand Blvd, St. Louis, MO 63107
HHRP/City of St. Louis Building Division - 3108 N Grand Blvd, St. Louis, MO 63107
HHRP/CDA - 3108 N Grand Blvd, St. Louis, MO 63107

Upload Insurance Certificate:

Lead Abatement Contractors— In addition to the above requirements or General Liability, Workers Compensation and Automobile Insurance Coverage, Lead Abatement Contractors will need additional insurance coverage, in addition to a Missouri State Lead License.

Pollution Liability and Lead Liability, for each occurrence, at least $300,000.00
Payment and Performance Bonds

All contractors are required to have their EPA Renovate Right Certificate. Please upload your certificate below. Use this link or this one to learn more.

Upload EPA Renovate Right Certificate:

I have read and understand the insurance requirements in order to participate in the Healthy Home Repair Program as a Qualified Contractor.

Authorized Signature Contractor's Representative:

Date:

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Upload W-9

Need a W-9? Use this link to access an electronic one.

Thank you for your application and interest in becoming a Healthy Home Repair Program contractor!

We will contact you within 10 working days, if you do not hear or would like to discuss the application with us; please contact us directly at (314) 771-5016 extension #10 or by email at kepstein@hhrp.missionstl.org.

Have questions? Call (314) 771–5116, extension #3 or email information@hhrp.missionstl.org.