Attachment 10 - SAFETY _ ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE.docx

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Attached to
Z1DA--PROJECT 640A0-21-100 Upgrade Multiple Fire Alarms Systems MPD Federal contract opportunity
Solicitation number
36C26123R0082
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

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This document outlines safety and environmental record requirements for a Department of Veterans Affairs solicitation to upgrade multiple fire alarm systems. To be eligible for consideration, contractors must have no more than three serious, one repeat, or one willful OSHA or EPA violations in the past three years and an Experience Modification Rate (EMR) of 1.0 or below. Offerors must submit a self-certification of their safety and environmental record on company letterhead, along with documentation of their current EMR from their insurance carrier. If the EMR exceeds 1.0, the carrier must provide an explanation on letterhead describing reasons for the rate and anticipated date for reduction. The solicitation number is 36C26123R0082 for opportunity Z1DA--PROJECT 640A0-21-100 to upgrade fire alarms under Veterans Health Administration VISN 21.

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PER VHA DIRECTIVE 7715 (06 April 2017) - SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR):

Contractor Certification Regarding Project:

To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.

All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer.

1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the contractor has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.

2. EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offerors’s insurance carrier and be furnished on the insurance carrier’s letterhead. If an Offeror’s EMR is above 1.0, Offeror shall submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.

2019
2020
2021

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.)

Number of violations from EPA within the last 3 years. Please attach explanation for any violations.

Company’s Current Insurance Experience Modification Rate (EMR) = (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature:

Print Name: _________________________________________________

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