EMR_Certification.docx
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- 1232SC18R0024
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EMR Certification form
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Contractor Certification Regarding Project: Project Title Here
| 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: ______________________________________________________
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