Attachment 1 - Experience Modification Rate Form 2022 Revised 2 2 2023.pdf
PDF 160 KB Posted
- Attached to
- Z1DA--679-23-101 | Special Roofing Replacements Federal contract opportunity
- Solicitation number
- 36C24724R0067
About this file
This document is an Attachment 1 - Experience Modification Rate Form for a federal contract opportunity. It requires the offeror to provide information about their OSHA 300 forms, including the number of man-hours, lost workday cases, and DART rate for the past three years. The offeror must also provide their insurance Experience Modification Rate (EMR) for the past three years. This information, along with the offeror's OSHA and EPA compliance history, will be used to ensure the contractor meets the EMR requirements indicated in the solicitation.
The related federal contract opportunity is for Special Roofing Replacements for Buildings 1, 4, 5, 12, 17, 18, 61, and 135 at the Tuscaloosa VA Medical Center. The work includes construction and replacement of the roofs for these buildings, and the contractor must comply with all VA safety rules, NFPA, EPA, and NEC codes. The contract has a performance period of 365 calendar days from the date of award.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24724R0067 0003.docx | DOCX document | |
| 36C24724R0067 0002.docx | DOCX document | |
| Roof Investigation Report - all combined.pdf | ||
| 36C24724R0067 0001.docx | DOCX document | |
| Pre- Bid Site Visit 6-3-24.pdf | ||
| Drawings 679-23-101.pdf | ||
| Past Performance Questionnaire.docx | DOCX document | |
| Specifications - Emergency Roofing Replacement 679-23-101.pdf | ||
| Attachment 2 - 852.219-75 VA NOTICE OF LIMITATIONS ON SUBCONTRACTING Jan 2023 Dev form.pdf | ||
| UPDATED DBA WAGES AL20240098.pdf | ||
| 36C24724R0067_1.docx | DOCX document |
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Text version
Attachment 1 Experience Modification Rate Form
Offeror To Complete & return with response to solicitation
Company Name: ______________________________________________________________________
Address: _____________________________________________________________________________
Telephone: _______________________ Email: _____________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022 Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).
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 disqualifies the contractor.)
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
2. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years :
The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases will be used to ensure the contractor meets Experience Modification Rate indicated in the solicitation.
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .