Contractor_Certification_Regarding_EMR.pdf

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Remove and Replace Roof CRL
Solicitation number
1232SD18R0018
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Contractor Certification Regarding EMR

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Contractor Certification Regarding Project: Remove and Replace Roof CRL

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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