Contractor_Certification_Regarding_EMR.pdf

PDF 88 KB Posted

Attached to
Replace Compressors for Constant Temperature Rooms in the NLGRP Federal contract opportunity
Solicitation number
128KAP18R0003
Issued by
Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Plains Area

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Contractor Certification Regarding EMR

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Contractor Certification Regarding Project: Install HVAC

2012 2013 2014 2015 Number of serious, willful, or repeat violations from OSHA within the last 4 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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