36C26320R0102-008.pdf

ADDITIONAL PRIME CONTRACTOR INFORMATION REQUIRED TO PERFORM A

DETERMINATION OF RESPONSIBILITY

Safety or Environmental Violations and Experience Modification Rating Information

1.) All Bidders/Offerors shall submit information pertaining to their past Safety and

Environmental record. The information must contain a certification that the bidder/offeror 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. If such certification cannot be made, a Bidder/Offeror shall explain why and submit as much information as possible regarding the circumstances of its past safety and environmental record, including the number of EPA violations and/or the number of serious, repeat, and/or willful OSHA violations, along with a detailed description of those violations.

2.) All Bidders/Offerors shall submit information regarding their current Experience

Modification Rate (EMR). This information shall be obtained from the Bidder’s/Offeror’s insurance carrier and be furnished on the insurance carrier’s letterhead. If a

Bidder/Offeror’s EMR is above 1.0, Bidder/Offeror must submit a written explanation of the

EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the elevated EMR and the anticipated date the EMR may be reduced to 1.0 or below.

3.) Self-insured contractors or other contractors that cannot provide their EMR rating on insurance letterhead must obtain a rating from the National Council on Compensation

Insurance, Inc. (NCCI) by completing/submitting form ERM-6 and providing the rating on letterhead from NCCI. Note: Self-insured contractors or other contractors that cannot provide

EMR rating on insurance letterhead from the states or territories of CA, DE, MI, NJ, ND, OH, PA, WA, WY, and PR shall obtain their EMR rating from their state-run worker’s compensation insurance rating bureau.

4.) If the NCCI cannot issue an EMR because the Bidder/Offeror lacks insurance history, Bidder/Offeror shall submit a letter indicating so from its insurance carrier furnished on the insurance carrier’s letterhead, and include a letter from the NCCI indicating that is has assigned

Bidder/Offeror a Unity Rating of 1.0.

5.) The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases, will be used to make an initial

Determination of Responsibility.

6.) This requirement is applicable to all subcontracting tiers, and prospective prime contractors are responsible for determining the responsibility of their prospective subcontractors.

Pre-Award Contractor Safety and Environmental Record Evaluation Form

Information provided below is current and applicable to Solicitation: 36C26320R0102

Company Name: _______________________

Address: ______________________________

Telephone: __________________________________ Fax: ___________________

Email: ________________________________________

Contact: _____________________________________________________________________

1. Utilizing OSHA 300 Forms, please complete the following information:

Category 2017 2018 2019

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.

Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.

1. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 238210

2. Who administers your company’s Safety and Health Program?

3. Company’s Insurance Experience Modification Rate (EMR): ___________________ http://www.osha.gov/pls/publications/publication.html