SAFETY - ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C26126R0008
About this file
This document is a Safety and Environmental Record Certification form for a federal contract opportunity involving elevator replacement at the Veterans Affairs Northern California Health Care System (VANCHCS). The certification requires contractors to meet specific safety and environmental compliance standards, including having no more than three serious, or one repeat, or one willful OSHA or EPA violations in the past three years, and maintaining an Experience Modification Rate (EMR) of 1.0 or less. Contractors must submit a self-certification of their safety record on company letterhead and provide documentation from their insurance carrier verifying their current EMR.
The related federal contract opportunity is a pre-solicitation for replacing five elevator systems across VANCHCS campuses in Martinez and Mare Island, California. The solicitation is a Service-Disabled Veteran-Owned Small Business (SDVOSB) set-aside with a NAICS code of 238290, size standard of $22 million. The contract will be a Firm-Fixed-Price with a period of performance of approximately 360 calendar days, and the estimated project value is between $2,000,000 and $5,000,000. The solicitation is scheduled to be issued around November 22, 2025, with offers limited to SDVOSB concerns only.
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Text version
PER VHA DIRECTIVE 7715 (06 April 2017) - SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR):
Contractor Certification Regarding Project:
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 Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer.
1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the contractor 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.
2. EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offerors’s insurance carrier and be furnished on the insurance carrier’s letterhead. If an Offeror’s EMR is above 1.0, Offeror shall submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
| 2022 |
| 2023 |
| 2024 |
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 disqualifies the contractor.)
Number of violations from EPA within the last 3 years. Please attach explanation for any violations.
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:
Print Name: _________________________________________________
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