36C25018B0807-007.docx
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36C25018B0807 6 - Offeror Safety and Environmental Certification.docx
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Contractor Certification Regarding Project: 539-16-209
| Number of violations from OSHA or EPA |
| 2015 |
| 2016 |
| 2017 |
SERIOUS
REPEAT
WILLFULL
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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