Contractor Certification Regarding Safety and Environmental.docx

This is a contractor safety and environmental certification form related to a VA chapel remodeling project (610A4-22-203) at the Fort Wayne VA Medical Center. The form requires contractors to disclose their OSHA violation history from the past 3 years (with explanations required for any violations) and their current Insurance Experience Modification Rate (EMR), which must be supported by a signed letter from their insurance carrier. The form notes that four serious violations, one repeat violation, or one willful violation could result in a determination of non-responsibility.

The associated project (Solicitation #36C25025B0010) involves remodeling the chapel at Fort Wayne VAMC, including demolition and construction work per specifications, with strict infection control requirements. The contractor must handle potential hazardous materials including asbestos and lead-based paint. The work is to be performed at 2121 Lake Ave., Fort Wayne, IN 46805, with a completion timeline of 183 calendar days from notice to proceed.