S02 Contractor EMR Certification Form - 553-21-202.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Replace Sinks and Counters 553-21-202
- Solicitation number
- 36C25024B0027
About this file
This document is a pre-award contractor experience modification rate form for solicitation 36C25024B0027 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 to replace sinks and counters. The form requests contact information and safety history for potential awardees, including OSHA recordable incident rates for the past three years, copies of 2020 OSHA forms, the contractor's current EMR rate from its insurance carrier, its NAICS code, and the name of its safety program administrator. It seeks this information to determine responsibility for any potential awardee in accordance with FAR requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25024B0027 0005.docx | DOCX document | |
| 36C25024B0027 0004.docx | DOCX document | |
| 36C25024B0027 0003.docx | DOCX document | |
| S06 553-21-202 new ICRA rev003.pdf | ||
| 36C25024B0027 0002.docx | DOCX document | |
| S04 Pre-Bid Conference Sign-In Sheet - 553-21-202.pdf | ||
| 36C25024B0027 0001.docx | DOCX document | |
| S04 Pre-Bid Site Visit Agenda 553-21-202 - signed.pdf | ||
| S02 SDVOSB Joint Venture Certification Attachment.docx | DOCX document | |
| S02 Wage Determination - MI20240101 mod 20240119.pdf | ||
| S02 RFI Form - 553-21-202.doc | DOC document | |
| S02 Drawings - 553-21-202.pdf | ||
| S02 Specifications book - 553-21-202 01.25.2024.pdf | ||
| 36C25024B0027_2.docx | DOCX document |
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25024B0027 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 |
| 2021 |
| 2022 |
| 2023 |
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) 2020 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: __________________________________
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): ______
File details come from the government source that posted it. Updated .