Attachment 4 Contractor Certification Regarding EMR.docx
DOCX document 14 KB Posted
- Attached to
- Somerville Main Bldg Addition and Renovation Federal contract opportunity
- Solicitation number
- 12805B22R0009
About this file
This document contains a contractor certification form regarding a project for the Somerville Main Building Addition and Renovation opportunity issued by the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Plains Area.
The contractor certification form requests information on the number of serious, willful, or repeat violations from OSHA within the last 4 years and requires an explanation for any violations, as three serious, one repeat, or one willful violation will result in the contractor being deemed non-responsible. The form also requests the contractor's current insurance experience modification rate and requires it to be supported by a signed letter from the contractor's insurance carrier on their letterhead. Space is provided for the contractor's signature, printed name, and title.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 12805B22R0009 Questions and Answers 2.pdf | ||
| Solicitation_12805B22R0009_Amd_0002.pdf | ||
| Sol_12805B22R0009_Amd_0001.pdf | ||
| 12805B22R0009 Questions and Answers.pdf | ||
| Attachment 1 Wage Determination TX20222035.txt | TXT text file | |
| Attachment 3 Combined Specs - Phase 2.pdf | ||
| Attachment 5 Pre-Award Survey Form.doc | DOC document | |
| Attachment 3 Combined Specs - Phase 1.pdf | ||
| Solicitation_12805B22R0009.pdf | ||
| Attachment 2 Combined Drawings - Phase 1.pdf | ||
| Attachment 2 Combined Drawings-Phase 2.pdf | ||
| Attachment 6 SAM Reps and Certs Form.docx | DOCX document |
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Text version
Contractor Certification Regarding Project: 12805B22R0009
| 2018 |
| 2019 |
| 2020 |
| 2021 |
Number of serious, willful, or repeat violations from OSHA within the last 4 years. Please attach explanation for any violations. (Three serious, one repeat, or one willful violation shall result in being determined non- responsible.)
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:
Typed Name:
Title:
File details come from the government source that posted it. Updated .