5- Exhibit A- Quantities Prices and Data.pdf

Exhibit A Solicitation No. 444710-CC-25 Subcontract No. TBD 01/11/24 Page 1 of 16

MISSION SUPPORT AND TEST SERVICES, LLC

FIRM-FIXED-PRICE SERVICES SUBCONTRACT

EXHIBIT A

QUANTITIES, PRICES AND DATA

TABLE OF CONTENTS

FORM TITLE PAGE

Form A Consideration Schedule Form B Subcontractor and Vendor List Form C Evaluation Criteria Form E Lower-Tier Subcontractor Experience Statement Form F Project Organization Description Form G Resumes of Key Personnel Form H Safety Program Form I Safety and Health History Form J Lower-Tier Subcontractor Safety and Health History

01/11/24 Page 2 of 16

FORM A CONSIDERATION SCHEDULE

NOTE: Form A, with the blanks filled in based on the awarded proposal(s) or agreement of the Offeror and CONTRACTOR shall become part of the resulting subcontract.

1. SCHEDULE OF QUANTITIES AND PRICES

The Prices shown are all-inclusive Firm-Fixed-Prices (including e.g., labor, materials, G&A, overhead, profit or fee, taxes (except sales tax)*, any other costs required to be paid by law, regulation, or ordinance, and any other cost of whatsoever nature). Payment of the Prices shall constitute full payment for the performance of the Work and covers all costs of whatever nature incurred by SUBCONTRACTOR in accomplishing the Work in accordance with the provisions of the Subcontract and are not subject to escalation for any cause, except as may otherwise be provided in this Subcontract.

The total Firm Fixed Price for the performance of all Work is [INSERT DOLLARS IN WORDS] dollars ($[ENTER

DOLLAR AMOUNT]).

*Sales tax is not included, but shall be added to each invoice as a separate line item if applicable to the CONTRACTOR under this Subcontract/Order in accordance with applicable state law.

For evaluation purposes only, the estimated period of performance is 90 Calendar Days. Start date of the project is estimated to be in March 2025. A firm project start date will be provided once final a drilling date is determined.

The breakdown of the fixed price services for payment purposes is detailed below:

Item Number Description of Services Firm Fixed Price

1. 01 Milestone

Training in Las Vegas or at NNSS, as required by Exhibit B, Statement of Work, and Exhibit E.

Reference Exhibit A, paragraph 3, Training and Badging below. (Note 01)

2. 02 Milestone

Mobilization to the Jobsite of all resources, including personnel, required to accomplish the work (Including Travel) (Note 02)

3. 03 Monthly Payment

Lodging required for the duration of the estimated 90 days of work. (Provide a daily cost of lodging, multiplied by number of rooms, multiplied by 90 calendar days for a firm fixed price.

$______/day Number of Rooms:

Lodging will be invoiced monthly. The aggregate of all lodging related line items will equal the firm fixed price provided in the consideration schedule.

4. 04 Monthly Payment

Furnish all necessary labor to adequately perform the task and always meet the minimum requirement of two personnel on site in 13 hour rotating shifts. (Note 03)

$_____/Hr for 13 hours a day 13 hours a day per employee at 90 Calendar days for firm-fixed-price.

Labor will be invoiced monthly. The aggregate of all labor related line items will equal the firm fixed price provided in the consideration schedule.

01/11/24 Page 3 of 16

5. 05

Milestone Payment

Demobilization from the Jobsite of all personnel and resources

Grand Total $

Note 01: Amount shown is a one-time fixed amount to be paid for all SUBCONTRACTOR personnel training labor costs, assuming forty (40) hours of training per SUBCONTRACTOR or lower-tier subcontractor employee as outlined in Exhibit E, E12. In the event the SUBCONTRACTOR requires additional time to complete the training, the SUBCONTRACTOR may submit a request for change for consideration. The request for change must identify hours per person and the number of personnel affected. The fixed hourly rate of $______ per hour will be utilized to negotiate any request for change. Requests for change will not be considered for newly assigned personnel after the initial crew has been trained. All requests for change must be negotiated and authorized in a written modification to the subcontract.

Note 02: Amount shown is one-time fixed amount to be paid for development of all required work control packages, assuming 40 hours each for ______individuals including travel. In the event the SUBCONTRACTOR requires additional time and travel, the SUBCONTRACTOR may submit a request for change for consideration. The request for change must identify actuals to date and the increase required, with the increase required in the number of hours and travel identified separately. The fixed hourly rate of $________ per hour will be utilized for any request for change. Only requests for change that have exceeded the 40 hours each for ___ individuals will be considered for negotiating any change. All negotiated changes will be authorized in a written modification to the subcontract.

Note 03: In providing the labor for 24/7 continuous drilling operations, no overtime will be permitted unless otherwise approved by the project team under unforeseen circumstances. If overtime is approved, the SUBCONTRACTOR will submit a change order proposal that will be reviewed by the CONTRACTOR for approval.

All negotiated changes will be authorized in a written modification to the subcontract.

2. MODIFICATION PRICING RATES

The Daily Rate to include all the items identified below will be use in the event a modification to extend the number of days is required. The Daily Rate provided in Subsection B below is a "fixed" rate for the purpose of negotiating Firm-Fixed-Price Subcontract modifications. The Daily Rate below shall apply to Subcontract modifications for the duration of the Subcontract. Any changes made to this Subcontract will be in accordance with Exhibit C, C-20 “Changes.” Changes include change orders, revisions, modifications, equitable adjustments, and anything else which would require or result in a modification to this Subcontract in accordance with the Changes Clause. The SUBCONTRACTOR shall adhere to the pre-established modification Daily Rate. The CONTRACTOR shall review all SUBCONTRACTOR quotes to ensure compliance with contractual terms.

A. Daily Rate: $_____________

B. Daily Rate may include but is not limited to the following:

• Lodging

• Per Diem

• Geologist Labor (Minimum of 2 geologists on site working 13 hour rotating shifts for 24/7 drilling operations)

01/11/24 Page 4 of 16

A. SUBCONTRACT MODIFICATION SUMMARY LEVEL BREAKDOWN

As part of the SUBCONTRACTOR’S submittal for modification pricing, a summary level breakdown of labor, materials and equipment shall be included. The SUBCONTRACTOR shall provide the following information at a minimum, but not limited to:

1. Labor shall be listed by labor category, work description, unit of measure, quantity, hourly labor rate burdened and unburdened, a description of the burden categories and burden amounts (i.e., %), and extended total. This shall also include a written explanation of the basis for the estimated labor hours for each labor category.

2. Materials shall be listed by item, stock number where applicable, unit of measure, unit price, quantity, and extended total. Miscellaneous items shall be completely defined. This shall also include a written explanation of the basis for the estimated materials quantities for each material type.

3. Equipment shall be listed by item, model number where applicable, unit of measure (daily, weekly, monthly), unit price, quantity, and extended total. This shall also include a written explanation of the equipment needs.

4. Additional design if required shall include the price of preparation of all detailed drawings, engineering specifications, a material list, and submittal of design drawings for review. Provide breakdown of design prices for both Design – 60 % Draft (Title II) and Design – 100 % Complete (Title III). This shall also include a written explanation of the necessity for additional design work.

Pricing received from Lower-tier Subcontractor(s) by the SUBCONTRACTOR shall conform to the same requirements noted above.

Certified Cost or Pricing Data: In addition to the requirements stated herein, Subcontract modifications which are likely to exceed $2,000,000 shall be governed by FAR clause 52.215-13, Subcontractor Certified Cost or Pricing Data-Modifications. SUBCONTRACTOR shall submit certified cost or pricing data and certification as required by that clause.

B. MODIFICATION BUY AMERICAN CERTIFICATION

Buy American Certification will be included in each Modification Request for Quotation (RFQ) for certification by the awardee that all construction materials furnished under the modification are of domestic origin or otherwise in compliance with the Buy American Act.

3. TRAINING AND BADGING

CONTRACTOR-Provided Training: After award and before SUBCONTRACTOR personnel may commence any on-site work at CONTRACTOR facilities, all SUBCONTRACTOR personnel (including any lower-tier Subcontractor personnel) scheduled to perform activity level work on-site will be required to complete, at a minimum, CONTRACTOR-provided General Training and Work Control Training. The total amount of training time for each individual is estimated to be 40 hours. The CONTRACTOR will provide this training one time for all SUBCONTRACTOR on-site personnel prior to commencement of on-site work at no cost to the SUBCONTRACTOR. The SUBONTRACTOR’S time for the initial training session(s) shall be compensated using the following hourly rate which shall apply for all SUBCONTRACTOR personnel who are required to take the training: $_____/Hr.” or The estimated cost to the SUBCONTRACTOR for the time its on-site personnel will be required to take the initial training is included in the Firm-Fixed-Price specified herein for the performance of this Subcontract. If, due to turnover of trained personnel, the SUBCONTRACTOR needs additional training sessions during performance of the work for replacement personnel, the CONTRACTOR will provide the training but will not compensate the SUBCONTRACTOR for the time spent in training by the additional personnel to replace those personnel already trained.

Personnel who have previously completed NNSS General Training are not required to be re-trained if this training is current. Check with the Subcontract Technical Representative (STR) after award.

01/11/24 Page 5 of 16

4. PAYMENT TERMS

Enter any prompt payments discount or Net 30 Days .

Electronic funds transfer is the preferred method of payment used by Mission Support and Test Services, LLC. To take advantage of this expedited payment process, complete FRM-0870. Link to form:

http://www.nnss.gov/docs/docs_procurement/frm0870.pdf

5. MEASUREMENT FOR PAYMENT

A. Firm-Fixed-Price Milestone Payments

Milestone Payments shall be made for the successful completion of the Line Items identified as Milestone Payments in the Consideration Schedule, Exhibit A, Form A. Milestone Payments shall be made in accordance with clause D-8, Invoicing and Payment (Exhibit D). All milestone payments in the for the subcontract shall be equal to the Total Firm-Fixed-Price identified in the Consideration Schedule.

For line items labeled Monthly Payments within the consideration schedule, invoicing will be submitted monthly to allow the SUBCONTRACOR payment throughout the duration of the subcontract. The Aggregate invoiced costs for line items labeled Monthly Payments will equal the firm fixed price total.

6. SUBCONTRACT VALUE

The Value of this Subcontract is To Be Determined dollars ($ To Be Determined). The total payments under this Subcontract shall not exceed Value of this Subcontract unless the value is modified by in writing by the Subcontract Administrator in advance.

http://www.nnss.gov/docs/docs_procurement/frm0870.pdf

01/11/24 Page 6 of 16

FORM B SUBCONTRACTOR AND VENDOR LIST

Subcontractor shall employ the following lower-tier subcontractors and/or vendors who will furnish major components, materials or equipment for performance of the work:

Name & Address

Work Description

Terms* Value Business Type *

If no lower-tier subcontracts or purchases are anticipated, enter the word “NONE.

NOTES: *

1. TERMS: Enter Lump Sum, Unit Price, etc.

2. Business Type: Enter SB for Small Business, SDB for Small Disadvantaged Business, WOSB for

Women-Owned Small Business, VOSB for Veteran-Owned Small Business, and SDVOSB for Service Disabled Veteran-Owned Small Business.

NOTE: This Form will become a part of the resultant subcontract.

01/11/24 Page 7 of 16

FORM C EVALUATION CRITERIA

1.

CONTRACTOR intends to award a subcontract resulting from this Solicitation to the responsible OFFEROR whose proposal conforms to the solicitation. CONTRACTOR reserves the right to determine that proposals are outside the competitive range at any time during the evaluation process. OFFERORS whose proposals are determined to be outside the competitive range will be promptly notified.

In its sole discretion, CONTRACTOR may, but is not required to:

A. Accept or reject any proposal for any reason with or without prior discussions with the OFFEROR;

B. Waive any requirements of this solicitation or the Solicitation Documents or waive any noncompliance in any proposal;

C. Make award decisions on the basis of the information and proposals received from the OFFEROR and/or additional information received from other sources;

D. Select one or more competitive proposals for further technical review prior to award;

E. Make an award with or without discussions;

F. Obtain additional information of whatsoever nature from any OFFEROR for consideration in the award decision;

G. Amend this solicitation for any reason whatsoever;

H. Cancel this solicitation for any reason whatsoever;

I. Take any other action whatsoever in relation to this solicitation.

2. GENERAL CONSIDERATIONS

In addition to the evaluation of each OFFEROR’S proposal, CONTRACTOR will consider each OFFEROR’S adherence to the terms and conditions. All Exceptions and Deviations will be evaluated on a case-by-case basis. Exceptions and Deviations may result in the proposal not being selected for award.

3. EVALUATION METHOD

A. LOWEST PRICE TECHNICALLY ACCEPTABLE (LPTA)

This procurement will use a Pass/Fail process to assess the technical merits of the proposal. Technical aspects of the proposal will be evaluated to determine if the OFFEROR’s proposal meets the minimum criteria and solicitation requirements. Award will be made to the responsive, responsible OFFEROR on the basis of the lowest evaluated price of proposals meeting the acceptability standards specified in each criterion for non-cost factors unless no proposals are received which specify delivery by the required delivery date. In this event, CONTRACTOR reserves the right to make award to that responsive, responsible OFFEROR providing the earliest delivery whose proposal conforms to the solicitation and minimum standards/requirements specified for each criterion, price and other factors considered. Failure to satisfy any of the minimum standards/requirements for each criterion will result in the Proposal not being evaluated further and therefore the OFFEROR will be eliminated from consideration.

Pass - Meets the minimum requirements specified in each criterion.

Fail - Does not meet minimum requirements specified in each criterion.

OFFEROR must receive a pass rating in all criteria to be considered for award.

01/11/24 Page 8 of 16

Pass/Fail Criteria

The following are mandatory minimum requirements. Failure to provide any one of the following criterions will cause the Proposal to be eliminated and not further evaluated:

1. Ability to provide a Geological Support Staffing Plan to include the SUBCONTRACTORS information and technical approach. The Plan shall provide, at a minimum, the following information:

1.1 Names and resumes of geologists assigned to the project

1.2 Provisions to provide backup geologists with the availability to be on-site within 24 hours

1.3 Geologist work rotation schedule

1.4 Lodging plan – lodging is available onsite at the NNSS or in nearby towns/cities of Las Vegas, Pahrump, or Beatty Nevada

1.5 Communication plan

1.6 Transportation plan

1.7 Affidavit from the SUBCONTRACTOR stating that all SUBCONTRACTOR’s personnel will adhere to the CONTRACTOR’s Operating Procedures listed in the Statement of Work, section B-3, Technical Specifications.

1.8 Site Safety Plan, including emergency preparedness plan, emergency contact list, personal protective equipment.

1.9 Details on how the SUBCONTRACTOR evaluates and maintains the qualifications of personnel.

2. Ability to provide geologists who have a minimum of two years of experience in performing similar duties outlined in the Operational Procedures specified in SOW, Exhibit B, section B-2.

3. Ability to provide full scope as described in exhibit B, SOW, no later than March 10th, 2025 (Actual start date may vary depending on drillers mobilization date).

B. Price Evaluation CONTRACTOR will review pricing for completeness, reasonableness and realism. The purpose of the review will be to ensure, to the maximum extent feasible, that OFFEROR'S proposed prices are complete and realistic in relation to the solicitation, and the technical proposals are reasonable in relation to known market pricing. Realism is the compatibility of the OFFEROR'S proposed price with proposal scope and required effort. Completeness is the responsiveness of the offer in providing the areas of price required by the RFP and scope of work. All the cost information required by the RFP must be submitted. An unrealistic price proposal may be grounds for eliminating a proposal from competition either on the basis that the OFFEROR does not understand the requirement or the OFFEROR has made an improvident proposal.

Although price will not be scored, it can be the determining factor between proposals within the competitive range. CONTRACTOR will evaluate proposals for award purposes by adding the total price for options to the total price for the base period. CONTRACTOR may determine that a proposal is unacceptable if the option prices are significantly unbalanced. Evaluation of the options will not obligate CONTRACTOR to exercise the option(s).

01/11/24 Page 9 of 16

4. PREPARATION OF PROPOSAL (Technical and Pricing) Proposals shall be submitted on the forms furnished, or copies thereof, and must be manually signed. No erasures are permitted. If changes appear on the forms, the erroneous information must have a single line drawn through the information and be initialed and dated by the person signing the proposal.

Proposals must be submitted in separate volumes: Technical and/or Management, and Price. The proposal shall contain all pertinent information requested in sufficient detail to permit a thorough evaluation. If the requested information is not located in the proper section, the information may be considered omitted.

a. Technical proposals submitted in response to this RFP shall comply with the following requirements:

• No cost information is to be included in the technical proposal.

• Resumes of employees who will be performing work.

• Proposal shall not merely offer to perform work IAW the special conditions but shall explain how the OFFEROR plans to accomplish the requirements. That is, repeating the special conditions without sufficient elaboration will not be acceptable.

b. Proposals will be evaluated as set forth in paragraph 3 Evaluation Method above.

c. Format and Content

OFFEROR shall include in its proposal the following:

Volume 1 – Technical information should clearly address each of the technical proposal evaluation criteria in paragraph A above. It should be presented in as much detail as practical and include the following as a minimum:

Form B – Subcontractor and Vendor List without Prices Form D – Experience Statement completed Form E – Lower Tier Subcontractor Experience Statement Form F – Project Organization Description Form G – Resumes of Key Personnel Geological Support Staffing Plan per Section B-2 of Exhibit B (Criterion 1) Resumes of Geologists with two years of experience per Form G of Exhibit A (Criterion 2) Ability to begin no later than March 10, 2025 (Criterion 3)

Volume 2 – Safety information shall be provided for the Determination of Responsibility

1. Form H – Safety Program

2. Form I – Subcontractor Safety and Health History

3. Form J – Lower-Tier Subcontractor Safety and Health History

Volume 3 – Pricing proposal shall include completed:

1. OFFEROR’S Proposal Letter, signed and dated

2. Form A – Consideration Schedule in its entirety,

3. Form B – Subcontractor and Vendor List with Prices

4. Key Personnel from Exhibit D, D-19

5. FRM-0870, Supplier Payment Information

Note 1: Provide one (1) electronic file copy Volume 1 Technical Proposal, one (1) electronic file copy Volume 2 Safety Proposal, one (1) electronic file copy Volume 3 Quality Assurance Proposal and one (1) electronic file copy Volume 4 Price Proposal to CONTRACTOR for evaluation. All information shall be printed single sided and shall not be a duplicate to ensure clarity of words and/or images.

Note: This Form is for evaluation purposes only and will not be a part of the resultant subcontract.

01/11/24 Page 10 of 16

FORM D EXPERIENCE STATEMENT

The OFFEROR submits the following statement as to its experience qualifications. In the case of a joint venture, separate forms will be submitted for previous experience of the joint venture and the experience of each party of the joint venture.

This company has been engaged in the contracting business under its present business name for years.

Experience in work of a nature similar in type and magnitude to that set forth in the Statement of Work (SOW) extends over a period of years.

All awarded contracts have been satisfactorily completed, except as follows (name any and all exceptions and reasons therefore, attaching additional pages if necessary):

The following contracts, covering work similar in type and magnitude to that set forth in the SOW, have been satisfactorily completed within the last 5 years preceding the due date for proposals specified in the solicitation or are now in progress for the following owners or prime contractors.

NAME, ADDRESS/CONTACT AND

TELEPHONE NUMBER

WORK

DESCRIPTION

VALUE LOCATION START/STOP

01/11/24 Page 11 of 16

FORM E LOWER-TIER SUBCONTRACTOR EXPERIENCE STATEMENT

This statement of experience qualifications is submitted for the following lower-tier subcontractor or supplier. In the case of multiple lower-tier subcontractors or suppliers, separate forms will be submitted for previous experience of each lower-tier subcontractor or supplier.

COMPANY NAME: PHONE:

CONTACT: FACSIMILE:

ADDRESS:

This company has been engaged in the contracting business under its present business name for years.

Experience in work of a nature similar in type and magnitude to that set forth in the SOW extends over a period of years.

All awarded contracts have been satisfactorily completed, except as follows (name any and all exceptions and reasons therefore, attaching additional pages if necessary):

The following contracts, covering work similar in type and magnitude to that set forth in the SOW, have been satisfactorily completed within the last 5 years preceding the due date for proposals specified in the solicitation or are now in progress for the following owners or prime contractors.

NAME, ADDRESS/CONTACT AND

TELEPHONE NUMBER

WORK

DESCRIPTION

VALUE LOCATION START/STOP

01/11/24 Page 12 of 16

FORM F PROJECT ORGANIZATION DESCRIPTION

OFFEROR is to attach an organizational chart with numbers and titles of key personnel and numbers and categories of home office personnel. Additionally, the OFFEROR is to provide a written description of the organization, defining lines of authority/responsibility/communication and the overall working of the organization with particular emphasis on interface and the procedures for monitoring and controlling the work.

OFFEROR is to attach a narrative, not to exceed three pages, describing its plan for Subcontract execution. This plan should be developed in conjunction with the organizational chart, resumes, and proposed lower-tier subcontractors/vendors. The narrative shall explain the management approach to this project as well as the flow of work from start to conclusion.

OFFEROR also must include capacity to perform information that links directly to each function listed on the organizational chart (i.e., the name of the person and the percentage of utilization in the program).

01/11/24 Page 13 of 16

FORM G RESUMES OF KEY PERSONNEL

OFFEROR is to provide a resume for each key person to be assigned to the Subcontract, containing at least the following information on each person.

1. TITLE:

2. NAME:

3. EDUCATION/QUALIFICATIONS:

4. PRESENT POSITION IN OFFEROR’S COMPANY:

5. RELEVANT EXPERIENCE:

6. EMPLOYMENT HISTORY:

7. CITIZENSHIP:

Attach and properly designate additional pages, if necessary.

NOTE: This Form is for evaluation purposes only and will not be a part of the resultant subcontract.

Approved personnel listed in the Special Condition titled “Approval of SUBCONTRACTOR Key Personnel” may not be replaced without CONTRACTOR’s approval of the replacement personnel.

01/11/24 Page 14 of 16

FORM H SAFETY PROGRAM

OFFEROR shall submit the following Safety and Health data with its proposal:

Environmental Safety & Health Requirements:

The SUBCONTRACTOR’s commitment to Environmental Safety and Health will be evaluated on their written

Safety Management Program as represented by the company’s written safety programs, policies, procedures, and understanding of requirements and safe job performance through:

Work Definition Hazard Identification & Control Hazard Performing Work Safely Self-Improvement Worker Training

Additional Information for evaluation purposes:

Resume of Company Safety Manager Resume of proposed Site Safety Representative (see Attachment A for qualification requirements) Completed Health History Forms

Subcontractor Lower-Tier Subcontractors

Insurance EMR verification for past three (3) years Subcontractor Lower Tier Subcontractors

Note: An Experience Modification Rate (EMR) of 1.0 or less is acceptable (Pass). If an EMR exceeds 1.0 for any year, the SUBCONTRACTOR and/or their LOWER-TIER SUBCONTRACTORS shall:

a. Supply information that clearly and completely explains the excessive rate(s)

b. Provide objective evidence that the root cause(s) of the excessive rate(s) have been identified and corrective actions implemented that have resulted in measurable improvements in safety performance, e.g.

lower incident rates, less severe incidents, and subsequent reductions in the EMR.

Pertinent information will be written into the appropriate Subcontract documents.

01/11/24 Page 15 of 16

FORM I SAFETY AND HEALTH HISTORY

Submittals:

1. Company Safety Program/applicable procedures

2. Resume of Company Safety Manager

3. Resume of proposed Site Safety Representative (reference Attachment A, Qualification Requirements for Safety Representative)

4. Insurance EMR verification

1. General Subcontractor Name:

2. NAICS Code: 541990- All other Professional, Scientific, and Technical Services

3. Number of Lower-Tier Subcontractors expected on-site?

4. Lower-Tier Subcontractor Name Discipline:

5. Workers’ Compensation Insurance Carrier letter providing your firm’s Interstate EMR for the three

(3) most recent years. Attach letter and input rates and total hours worked.

Year: EMR: Insurance Carrier:

Year: EMR: Insurance Carrier:

Year: EMR: Insurance Carrier:

6. Number of OSHA Inspections previous 5 years. Year(s):

7. Number of OSHA Citations previous 5 years Type:

8. Use your OSHA 300 Log to fill in number of injuries and illnesses for previous three years:

a) Number of lost workday cases Year:

# Hours Worked:

b) Number of restricted workday cases Year:

# Hours Worked:

c) Number of cases with medical attention only

Year:

# Hours Worked:

d) Number of fatalities Year:

# Hours Worked:

9. Explanation for EMR if greater than 1.0 :

01/11/24 Page 16 of 16

FORM J LOWER-TIER SUBCONTRACTOR SAFETY AND HEALTH HISTORY

1. Lower-Tier Company Name:

2. NAICS Code: 541990- All other Professional, Scientific, and Technical Services

3. Name of General Subcontractor

4. Workers’ Compensation Insurance Carrier letter providing your firm’s Interstate EMR for the three

(3) most recent years. Attach letter and input rates and total hours worked.

Year: EMR:

Year: EMR:

Year: EMR:

5. Use your last year’s OSHA No. 300 Log to fill in number of injuries and illnesses:

a) Number of lost workday cases

Hours Worked:

b) Number of restricted workday cases

c) Number of cases with medical attention only

d) Number of fatalities

6. Number of OSHA Inspections previous 5 years. Year(s):

7. Number of OSHA Citations previous 5 years Type: (De minimus, Serious, Willful, Repeat)

8. Do you have a written safety program? Yes No

9. Have you submitted the safety program to the General Contractor for their approval? Yes No

10. Explanation for EMR greater than 1.0