36C26119B0015-011.docx

CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL

Contractor Certification Regarding Project: 654-17-706

PER VHA DIRECTIVE 7715 (06 April 2017): SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR): To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.

All Bidders shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their bid.

1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the bidder has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.

EMR: All bidders shall submit information regarding their current EMR. This information shall be obtained from the bidder’s insurance carrier and be furnished on the insurance carrier’s letterhead.

Number of serious, willful, or repeat violations from OSHA within the last 3 years.

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: ______________________________________________________