Contractor_Certification_Regarding_EMR.pdf
PDF 33 KB Posted
- Attached to
- Replace Sign
- Solicitation number
- 1232SD18R0022
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Contractor Certification Regarding EMR
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Contractor Certification Regarding Project: Replace Sign
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 Sign
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