EMR_certification.pdf

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Replace & Relocate 2 Electric Panels Bldg 177C
Solicitation number
1232SC18R0019
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EMR certification

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Contractor Certification Regarding Project: Replace & Relocate Two Electric Panels, Bldg 177C

2014 2015 2016 2017 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: ______________________________________________________

Contractor Certification Regarding Project: Replace & Relocate Two Electric Panels, Bldg 177C

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