Attachment 1 - Experience Modification Rate Form.pdf
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- Solicitation number
- 36C24726R0024
About this file
This document is an Experience Modification Rate (EMR) Form attached to Request for Proposal (RFP) No. 36C24726R0024. The form requires offerors to provide detailed workplace safety and insurance information for the years 2023-2025, including man hours, OSHA recordable cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations.
Contractors must complete the form by documenting their safety metrics and attach copies of OSHA 300 and 300a Forms. The government will use this information, along with data from OSHA and EPA online inspection history databases, to verify the contractor meets the Experience Modification Rate requirements specified in the solicitation. Notably, contractors with four serious violations, one repeat violation, or one willful violation will be disqualified from the procurement.
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Attachment 1 - RFP No. 36C24726R0024 Experience Modification Rate Form
Offeror To Complete & return with response to solicitation
Company Name: ______________________________________________________________________
Address: _____________________________________________________________________________
Telephone: _______________________ Email: _____________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2023 2024 2025 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. (Four serious, one repeat, or one willful disqualifies the contractor.)
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.
2. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years :
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 ensure the contractor meets Experience Modification Rate indicated in the solicitation.
http://www.osha.gov/pls/publications/publication.html VHAV07PowerJ1 Cross-Out
File details come from the government source that posted it. Updated .