Attach 06 Contractor Certification Regarding EMR.docx
DOCX document 14 KB Posted
- Attached to
- Clay Center Shade Structures Phase II Federal contract opportunity
- Solicitation number
- 12805B23R0016
About this file
This document contains a contractor certification form and information on a related federal contract opportunity for shade structures. The contractor certification form requests information on any OSHA violations from the past four years and the contractor's current insurance EMR rating, which must be supported by a signed letter from the contractor's insurance carrier.
The related federal contract opportunity is solicitation number 12805B23R0016 for Clay Center Shade Structures Phase II from the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Plains Area. The solicitation and attachments provide additional details on the opportunity to build shade structures. Offerors should review Section L for instructions and information on a scheduled site visit.
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Text version
Contractor Certification Regarding Project: 12805B23R0016Clay Center Shade Structures Phase II
| 2018 |
| 2019 |
| 2020 |
| 2021 |
Number of serious, willful, or repeat violations from OSHA within the last 4 years. Please attach explanation for any violations. (Three serious, one repeat, or one willful violation shall 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:
File details come from the government source that posted it. Updated .