F5084 - Principal Contractor Details and Bond Estimate

Queensland Principal Contractor’s Details and Bond
Government Estimate

 

Application details
Department of Transport and Main Roads reference number

[TR |

 

 

Pursuant to the conditional approval of the subject application, | nominate the following as the principal contractor for the works. |
request that you deal with the principal contractor for all matters relating to the construction works.

Applicant’s name

Applicant's signature Date

/ /

 

 

 

 

 

Principal contractor’s details
Legal name Australian Business Number (ABN)

 

Registered address

 

 

Postcode

 

Physical address

 

 

 

Postcode

 

Telephone number (work hours) Telephone number (after hours) Mobile number

Email address

Primary contact person (overseer) Position

Telephone number (work hours) Telephone number (after hours) Mobile number

Prequalification status (please check one)
Department of Transport and Main Roads prequalified Prequalified number

 

 

 

 

Not Department of Transport and Main Roads Attach evidence of:
prequalified i. previous construction works (preferably on a State-controlled road)
ii. ability to carry out the works in accordance with the approved plans,
standards and specifications
iii. qualifications and experience of the primary contact person
(overseer), including the Registered Professional Engineer of
Queensland number.

 

Principal contractor’s insurance and indemnity (please check if attached)
| Attached is the Deed of Indemnity for road works on a State-controlled road (form F5109) signed by the principal contractor.

| Attached is evidence of the principal contractor’s public liability insurance policy of no less than $20 million that notes the
Department of Transport and Main Roads interest on the policy.

Construction works costs
Estimated cost of the works Bond amount

[s IIs

| Attached are details supporting the estimation of costs of works (for example, bill of quantities).

 

 

 

Privacy statement: The Department of Transport and Main Roads is collecting the information on this form for the purpose of managing the road works (under s33 of
the Transport Infrastructure Act 1994) that are being undertaken by a third party with respect to an application for such works. The details will not be disclosed to any
other third party without your consent unless required by law.

 

 

 

TRB Forms Area Form F5084 CFD V01 Jun 2015