1. Att-5 EMR Contractor Certification.pdf

132 KB Posted

Attached to
Wellington Barn Cold Room Retrofit
Solicitation number
12305B23R0013
Issued by

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This document is an Experience Modification Rate (EMR) Contractor Certification template regarding the Wellington Barn Cold Room Retrofit project. The template requires contractors to disclose the number of serious, willful, or repeat OSHA violations in the last three years and provide an explanation for any violations. It also requires contractors to disclose their current insurance EMR rating and provide a signed letter from their insurance carrier to support the stated EMR. The related federal contract opportunity is solicitation number 12305B23R0013 issued by the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Northeast Area for retrofitting the cold room at the Wellington Barn facility. The solicitation seeks to award a contract for the specified cold room retrofit project.

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Other files

File Type Posted
SF30 Solicitation Amend 0001- 12305B23R0013-RFI QandA Wellington Barn Cold Room.pdf PDF
RFP w-SF1442 12305B23R0013-.pdf PDF
1. Att-2 Drawings pgs 15.pdf PDF
1. Att-1 SOW-Specs pgs 336.pdf PDF
1. Att-7 ARS 372 Contractors Request for Payment Transmittal.pdf PDF
1. Att-8 Price Breakout-Estimate.pdf PDF
1. Att-6 ARS 371 Construction Progress and Payment Schedule.pdf PDF
1. Att-3 WD DB-NY20230032-Jun 2023.pdf PDF
1. Att-4 Self Performed Work Worksheet.pdf PDF

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Attachment-5

Experience Modification Rate (EMR) Contractor Certification Regarding Project: Project Title Here

2018 2019 2020 2021 Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful violation could result in being determined non-responsible.)

Company’s Current Insurance Experience Modification Rate (EMR) = _____________

(Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature: ______________________________________________

Typed Name: ______________________________________________________

Title: ______________________________________________________

Attachment-5
Experience Modification Rate (EMR)
Contractor Certification Regarding Project: Project Title Here

File details come from the government source that posted it. Updated .