Service Partner Application

LET’S BUILD BRIGHTER FUTURES TOGETHER

Complete the application below for the opportunity to work with Quality Care as a service partner.

Company Name*
Account Payable To
(If your check should be made payable to a name other than the Company Name provided above, please let us know.)
Organizational Form*
Company Address*
Street Address Address Line 2 City State ZIP Code
Billing Address
(If different than Company Address)

Street Address Address Line 2 City State ZIP Code
Primary Contact - Name*
First Last
Primary Contact - Title
Primary Contact - Mobile Phone
Primary Contact - Office Phone
Primary Contact - Email
Secondary Contact - Name
First Last
Secondary Contact - Title
Secondary Contact - Mobile Phone
Secondary Contact - Office Phone
Secondary Contact - Email
Administrative Contact - Name
First Last
Administrative Contact - Title
Administrative Contact - Mobile Phone
Administrative Contact - Office Phone
Administrative Contact - Email
Experience
How many years has your company provided snow and ice removal services?
How many years has your company provided other maintenance services?
Plowing Equipment and Crew Currently Available
8' blade with 3/4 ton truck (or larger) and operator
Indicate quantity
10' blade with one ton truck (or larger) and operator
Indicate quantity
V-plow with 3/4 ton truck (or larger) and operator
Indicate quantity
8' pusher with skid loader and operator
Indicate quantity
10' pusher with skid loader and operator
Indicate quantity
12' pusher with backhoe and operator
Indicate quantity
14' pusher with backhoe and operator
Indicate quantity
16' pusher with small payloader and operator
Indicate quantity
20' pusher with large payloader and operator
Indicate quantity
Truck salter with 3/4 ton truck (or larger) and operator
Indicate capacity and quantity
Other plowing equipment
Sidewalk Equipment and Crew Currently Available
21" pusher shovel with operator
Indicate quantity
ATV or utility tractor with plow and operator
Indicate quantity
ATV or utility tractor with salt spreader and operator
Indicate quantity
ATV or utility tractor with plow and salt spreader and operator
Indicate quantity
Walk-behind broom
Indicate size and quantity
Skid steer with attachment and operator
Indicate size and quantity
Other sidewalk equipment
Are you willing to take on jobs with hand work or sidewalks only?
- Yes
- No
Insurance Requirements
If you are awarded a service provider contract with Quality Care, you will need to provide the following insurance. Please check each box below to indicate that you agree to these terms and conditions.
Applicant will carry Comprehensive Liability Insurance in the amount of $2,000,000 combined single coverage and Automobile Liability Insurance covering bodily injury and property damage in the amount of $1,000,000 combined single limit.
- Agree
- Disagree
Applicant will name Quality Care as an Additional Insured.
- Agree
- Disagree
Applicant will maintain workers compensation insurance for himself/herself and all employees.
- Agree
- Disagree
Applicant understands that if he/she has any sub-contractors, service providers, or agents, these same requirements apply to each sub-contractor, service provider, or agent.
- Agree
- Disagree

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IOWA CITY | CORALVILLE

428 WESTCOR DRIVE
CORALVILLE, IA 52241

319.354.3108

customerservice@quality-care.com

CEDAR RAPIDS

319.366.7822

customerservice@quality-care.com

BUSINESS HOURS
Our support team is available to help you by phone at 319.354.3108. You may also stop by our office during regular business hours.

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Service Partner Application

LET’S BUILD BRIGHTER FUTURES TOGETHER

Experience

Plowing Equipment and Crew Currently Available

Sidewalk Equipment and Crew Currently Available

Insurance Requirements

IOWA CITY | CORALVILLE

CEDAR RAPIDS