Attachment 1 - Experience Modification Rate Form.pdf
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- Solicitation number
- 36C24726R0022
About this file
This is an Experience Modification Rate Form for RFP No. 36C24726R0022 that offerors must complete and return with their solicitation responses. The form requires companies to provide basic identifying information including company name, address, telephone, email, and contact person.
The form requests detailed occupational safety and health data for the three-year period spanning 2022 through 2024. Offerors must complete a table with four categories of information: total man hours worked at jobsites and offices; number of cases involving days away from work, restricted activity, or both (as reported in Columns H and I of OSHA 300 forms); the calculated Days Away, Restricted, or Transferred (DART) rate using the formula of cases multiplied by 200,000 divided by man hours; and the number of serious, willful, or repeat violations issued by OSHA within the past three years with required explanations for any violations. Disqualifying criteria include four serious violations, one repeat violation, or one willful violation. Offerors must also provide their company's Insurance Experience Modification Rate (EMR) for the past three years and attach copies of OSHA 300 and 300a forms. The government will use the submitted 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.
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Attachment 1 - RFP No. 36C24726R0022 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.
http://www.osha.gov/pls/publications/publication.html VHAV07PowerJ1 Cross-Out
File details come from the government source that posted it. Updated .