Attachment 1_Experience Modification Rate Form.pdf

This is an Experience Modification Rate Form that offerors must complete and return with their response to RFP No. 36C24726R0083.

Offerors are required to provide company information including name, address, telephone, email, and contact person, followed by detailed safety and workers' compensation data. Section 1 requires completion of a three-year data table (2023-2025) derived from OSHA 300 Forms, including: total man hours worked at jobsites and offices; number of cases involving days away from work, restricted activity, or both (from OSHA 300 Columns H and I); calculated DART rate (days away, restricted, or transferred cases multiplied by 200,000 divided by man hours); and the number of serious, willful, or repeat OSHA violations within the past three years with attached explanations. Offerors are disqualified if they have four or more serious violations, one or more repeat violations, or one or more willful violations. Section 2 requires offerors to provide their company's Insurance Experience Modification Rate (EMR) for the past three years. Offerors must attach copies of completed OSHA 300 and 300a Forms, accessible through the OSHA publications search page. The government will evaluate the submitted information along with data obtained from OSHA and EPA online inspection history databases to verify the contractor meets the Experience Modification Rate threshold specified in the solicitation.