Attachment 1 - Experience Modification Rate Form.pdf
PDF 310 KB Posted
- Solicitation number
- 36C24726R0038
About this file
This document is an Experience Modification Rate Form (Attachment 1) for Request for Proposal (RFP) No. 36C24726R0038. The form requires offerors to provide detailed workplace safety and insurance information for the years 2022-2024, including number of man hours, workplace injury cases, Days Away, Restricted, or Transferred (DART) rate, and OSHA violations. Contractors must complete the table with 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 evaluate the contractor's safety performance and determine if they meet the Experience Modification Rate requirements specified in the solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24726R0038 0005.docx | DOCX document | |
| Attachment 8 Update Drawings 619-CSI-904 2-19-26.pdf | ||
| Attachment 10 RFI Responses.docx | DOCX document | |
| Attachment 7 Updated Specifications 619-CSI-904 Combined Set.pdf | ||
| 36C24726R0038 0004.docx | DOCX document | |
| 36C24726R0038 0003.docx | DOCX document | |
| Attachment 9 - Site visit attend.pdf | ||
| 36C24726R0038 0002.docx | DOCX document | |
| 36C24726R0038 0001.docx | DOCX document | |
| Attachment 3 - Past Performance Questionnaire -PPQ.pdf | ||
| Attachment 7 - Specifications - Symbia Evo - 619-CSI-904.pdf | ||
| Attachment 2 - SBA Vet SB Cert Program Class Dev.pdf | ||
| Attachment 5 - Wage Determinations.pdf | ||
| 36C24726R0038.docx | DOCX document | |
| Attachment 4 - Itemized Cost Breakdown.xlsx | XLSX spreadsheet | |
| Attachment 6 - INVOICING.pdf | ||
| Attachment 8 - Drawings.zip | ZIP file |
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Attachment 1 - RFP No. 36C24726R0038 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 2022 2023 2024 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.
File details come from the government source that posted it. Updated .