Attachment 1 - Experience Modification Rate Form.pdf
PDF 305 KB Posted
- Attached to
- 508-24-102 | Replace AHUs 2, 3, 5, 17, and 19
- Solicitation number
- 36C24726R0013
About this file
This document is an Experience Modification Rate Form (Attachment 1) for Request for Proposal (RFP) No. 36C24726R0013. The form requires offerors to provide detailed occupational safety and health information, including the number of man hours, work-related injury cases, Days Away, Restricted, or Transferred (DART) rates, and OSHA violations for the years 2023, 2024, and 2025. Offerors must attach copies of their OSHA 300 and 300a Forms and disclose their Insurance Experience Modification Rate (EMR) for the past three years.
The form explicitly states that the submitted information, along with data from government systems like OSHA and EPA online inspection history databases, will be used to verify that the contractor meets the Experience Modification Rate specified in the solicitation. Contractors are warned that four serious violations, one repeat violation, or one willful violation will result in disqualification. The form provides a URL for accessing OSHA publications and requires companies to complete all sections with their specific safety and health performance metrics.
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Text version
Attachment 1 - RFP No. 36C24726R0013 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 .