Attachment 5 - Contractor Certification Regarding EMR.pdf
PDF 103 KB Posted
- Attached to
- El Reno Road Repair
- Solicitation number
- 12805B24R0002
About this file
This document is a contractor certification form related to a federal contract opportunity for El Reno Road Repair from 2022 to 2023. The form requires contractors to disclose the number of serious, willful, or repeat violations from OSHA in the last 4 years and provide an explanation for any violations, as three serious, one repeat, or one willful violation would result in being deemed non-responsible. Contractors must also disclose their current insurance experience modification rate and provide a signed letter from their insurance carrier on letterhead supporting the reported rate. The related federal contract opportunity was solicited by the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Plains Area under solicitation number 12805B24R0002 for El Reno Road Repair services.
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Text version
Contractor Certification Regarding Project: 12805B24R0002 El Reno Road Repair
2020 2021 2022 2023 Number of serious, willful, or repeat violations from OSHA within the last 4 years. Please attach explanation for any violations. (Three serious, one repeat, or one willful violation shall 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:
File details come from the government source that posted it. Updated .