Attachment 1 - Experience Modification Rate Form.pdf
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- Solicitation number
- 36C24726Q0449_1
About this file
This is an Experience Modification Rate Form template that offerors must complete and return with their response to a federal solicitation. The form requires contractors to provide company identifying information including name, address, telephone, email, and primary contact details.
Section 1 requires offerors to complete a data table using OSHA 300 Forms, providing three years of safety metrics (2023-2025): total man hours for jobsite and office operations, number of cases involving days away from work or restricted activity, the calculated Days Away, Restricted, or Transferred (DART) Rate, and the number of serious, willful, or repeat OSHA violations. Offerors must attach copies of OSHA 300 and 300a Forms with their submission. Section 2 requests the six-digit North American Industrial Classification System (NAICS) code applicable to the acquisition. Section 3 asks who administers the company's Safety and Health Program. Section 4 requires disclosure of the company's Insurance Experience Modification Rate (EMR) for the past three years. The form notes that an EMR greater than 1.0 may disqualify an offeror. The government will cross-reference submitted information with data from OSHA and EPA online inspection history databases to verify the contractor meets the Experience Modification Rate threshold specified in the solicitation.
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Attachment 1 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. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition:
3. Who administers your company’s Safety and Health Program? __________________________________
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than
1.0 may disqualify the offeror): _______________________________________________________________
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
File details come from the government source that posted it. Updated .