36C25018B0197-007.docx

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Install PA Systems in Trailers 539-18-201 Federal contract opportunity
Solicitation number
36C25018B0197
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10

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36C25018B0197 S02 - Contractor Certification Regarding EMR.docx

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Contractor Certification Regarding Project: 539-18-201

2013
2014
2015
2016

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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