Attachment 4 Contractor Certification Regarding EMR.docx

DOCX document 14 KB Posted

Attached to
Renovation of Metabolic Research Lab.
Solicitation number
12805B22R0017
Issued by

About this file

This document contains a contractor certification form and details of a related federal contract opportunity for renovation services. The contractor certification form requests information on any OSHA violations incurred by the company within the last four years and the current insurance experience modification rate, to be supported by a letter from the contractor's insurance carrier.

The federal contract opportunity is being offered by the United States Department of Agriculture Agricultural Research Service Plains Area Office to renovate the Metabolic Research Unit located in Grand Forks, North Dakota. The contractor will provide all labor, materials, plant, equipment and transportation to perform the required renovation work in accordance with the plans and specifications, including the addition of shade structures. The magnitude of the construction project is estimated to be between $1,000,000 to $5,000,000.

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Contractor Certification Regarding Project: 12805B22R0017

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 .