Prospective Vendor Application

:: Company Information ::
Company Name:
Contact:
Address:
City, State, Zip:
Phone:
Fax:
Cell:
email:
Web Site:
Type of Business:
Federal ID:

:: Experience ::
How many years has your company been in the industry?  
What is the current size of your field operations? 
What is the current size of your office operations?
Do you use subcontractors? Yes    No
If yes, how many?
Do you require insurance or background checks on your subcontractors and employees?
 Yes    No
What are your business days of the week? 
What are your business hours? 
Are you available to work on the weekends? Yes    No
Do you have computers with internet service? Yes    No
Do you have laptops and wireless cards? Yes    No
Do you have scanning ability? Yes    No
Do you have digital cameras with minimum 4 mega pixel? Yes    No
Please list all license, issuing affiliation and expiration date:
Please list all business organization affiliations:

List the top three companies you support by volume:

Company: # of Years: Volume:

Company: # of Years: Volume:

Company: # of Years: Volume:

Please list your service areas:

:: Insurance Requirements ::

General Insurance Requirements/ Policy Limits

>> Commercial General Liability

  • $1,000,0000 each occurrence
  • $50,000 damage to rented premises
  • $5,000 medical expense
  • $1,000,000 personal & advertising injury
  • $2,000,000 general aggregate
  • $2,000,000 product/completed operations aggregate
  • MHS Customer Service, Inc. shall be named as Additional Insured on form CG
    2010 1185 or its equivalent including Primary and Non-contributory wording
  • Waiver of Subrogation in favor of MHS Customer Service, Inc.

>> Automobile Liability

  • $1,000,000 combined single limit
  • If your company does not have any owned autos, the policy shall be written
    using symbol 8 and 9 (non-owned and hired autos)
  • MHS Customer Service, Inc. shall be named as additional insured
  • Waiver of Subrogation in favor of MHS Customer Service, Inc.

>> Workers Compensation

  • $1,000,000 each occurrence
  • $1,000,000 each employee
  • $1,000,000 policy limit
  • Waiver of Subrogation in favor of MHS Customer Service, Inc.

>> Errors and Omissions (applies to bank work only)

  • $1,000,000 each claim for the policy period
  • $1,000,000 general aggregate for the policy period
  • List the deductible for each and every claim

:: Business References ::

Supply verifiable work history and reference list:

Business:

Company: Contact : Phone:

Company: Contact : Phone:

Company: Contact : Phone:

Personal:

Contact: Relation : Phone:

Contact: Relation : Phone:

Is your company certified as:

Minority Women Disabled Veteran Disabled Not Diverse Owned
Do you currently have a quality assurance program in place? Yes    No
Do you currently have a safety program in place? Yes    No
Do you have a training process, if so what type of training do you provide?
How do you insure quality in your results?

:: Vendor Background ::
Before a Vendor is approved to service our account all owner(s) and/or principals will be required to complete and pass a background check. MHS will not employ vendors who have been convicted of a crime (except misdemeanor traffic violations which have not resulted in either personal injury or death). If a member of your firm does not successfully pass the background check, that individual will not be permitted to service customers on behalf of MHS.

MHS has elected Info Cubic as their Employment Screening Company that will administer and
process all background investigations for its vendor network. The fee for the required
background check is $59.75. MHS requires a copy of the signed and dated release form along
with a “pass” background check to be submitted with the application package. The form is
attached below.

The background check includes the following parameters:

  • Social Security Number trace
  • A review of any state and federal felony convictions
  • A review of state and federal misdemeanor convictions for crimes that would present an
    unreasonable risk of harm to others or their property.
  • Any pending deferred adjudications with respect to the above items for the seven years
    prior to the date of the background check.
  • A review of the national sexual offender database. The background check was
    completed in the county in which the officer, owner and employee has resided,
    currently resides and/or has been, or is currently employed.
  • Office of Foreign Asset Control’s list of prohibited individuals

:: Required Items That Need To Be Return ::
  • MHS application
  • Background check signed authorization with passing results
  • Form W-9
  • Copy of applying company's business license and contractor license
  • Workers Compensation Insurance Certificate
  • Commercial General Liability Insurance Certificate
  • Commercial Auto Insurance Certificate
  • Errors and Omission Insurance Certificate