Supplier Diversity Form

Liberty Mutual is committed to supplier diversity. If you wish to be considered as a supplier and to participate in bidding opportunities, please complete the following form. Upon receipt, we will forward your company’s profile to the appropriate purchasing manager for entry into our database of interested suppliers. We reference this database when considering bid lists and RFIs.

* = Required field

* Company Name:
* Street Address:
* City:
* State:
* ZIP Code:
* Principal Contact:
* Title:
Email:
Confirm Email:
Website Address:
* Phone Number:
FAX Number:
Dun & Bradstreet Number:
* Number of Employees:
* Annual Revenue:
* Year Founded:
If You Are Inquiring in Reference to a Posted Sourcing Opportunity, Please Indicate which One:
* Please Describe Type of Business: (Limit entry to one paragraph—up to 500 characters)
* Service Area:	Local Regional National
* Please Specify Service Area:
* Is Your Company Certified as a Minority-Owned Business?	Yes No
* Certified by Whom?
* Certification Number:
* Certificate Expiration Date:
* Minority Classification:	African American Hispanic American Asian Indian American Asian Pacific American Native American Minority Woman-Owned Non-Minority Woman-Owned Other
* Please Specify:
Please Provide the Names of Three Major Clients:	1. 2. 3.
* Has Your Company Ever Been a Supplier with Liberty Mutual?	Yes No
* Please Indicate Liberty Mutual Contact:
* How Did You Learn About Our Program?
* = Required field