Contractor_Certification_Regarding_EMR.docx

DOCX document 13 KB Posted

Attached to
Variable Frequency Drive (VFD) replacement Federal contract opportunity
Solicitation number
81J81981690002
Issued by
Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Pacific West Area

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CONTRACTOR CERTIFICATION

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Contractor Certification Regarding Project: Plumbing Renovations in Building 107, Tucson, AZ.

2015
2016
2017
2018

Number of serious, willful, or repeat violations from OSHA within the last 4 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful violation could result in being determined non-responsible.)

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: ______________________________________________________

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