36C25019B0007-005.docx

DOCX document 13 KB Posted Mar 11, 2019

Attached to: Correct OIT Deficiencies 610A4-16-101
Solicitation number: 36C25019B0007
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10

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36C25019B0007 Contractor Certification Regarding Safety and Environmental.docx

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Contractor Certification Regarding Project: 610A4-16-101

2016

2017

2018

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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