Contractor_Certification_Regarding_EMR.PDF

PDF 40 KB Posted

Attached to
Quonset Repair and Repaint Federal contract opportunity
Solicitation number
919637
Issued by
Department of Agriculture Agricultural Research Service Central Program Planning Coordination and Support

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Contractor Certification

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Contractor Certification Regarding Project: Upgrade Cold Rooms HVAC & Controls

2014 2015 2016 2017 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 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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