S02 - Contractor EMR Certification Form - 515-21-103.pdf
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- Solicitation number
- 36C25022B0037
About this file
This pre-solicitation notice and related federal contract opportunity document provide details for the replacement of elevators at the Veterans Administration Medical Center in Battle Creek, Michigan. The project scope involves furnishing all labor, tools, materials, equipment and supervision to replace elevators in five buildings on site. The opportunity is set aside exclusively for verified Service-Disabled Veteran Owned Small Businesses. The North American Industry Classification Code is 238990 for all other specialty trade contractors with a small business size standard of $16.5 million. The acquisition will result in a firm fixed price contract between $1 million to $5 million with award intended within 120 days of bid opening. Interested parties should monitor the Contract Opportunities website for issuance of the solicitation on or around June 3rd, 2022 which will include qualification requirements, a pre-bid site visit, response submission details and a project period of performance of 730 calendar days.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25022B0037 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
Category 2018 2019 2020 2021
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.
2. Please attach copies of the following documents: a)2019 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b)Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: ________238990__________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______ http://www.osha.gov/pls/publications/publication.html
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