Attachment 4 - Contractor Certification Regarding EMR.pdf
PDF 161 KB Posted
- Attached to
- Drill Water Well For Livestock Federal contract opportunity
- Solicitation number
- 1232SA25Q0347
About this file
Attachment 4 is a Contractor Certification form for Project 12805B24Q0606 that requires contractors to disclose their Occupational Safety and Health Administration (OSHA) violation history and current Insurance Experience Modification Rate (EMR). The form mandates reporting the number of serious, willful, or repeat OSHA violations from the last 4 years (2019-2022), with a warning that three serious, one repeat, or one willful violation will result in being deemed non-responsible. Contractors must also provide their current EMR, supported by a signed letter from their insurance carrier on official letterhead. The document includes signature lines for a company representative to complete the certification, including space for a signature, typed name, and title.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| RFP__1232SA25Q0374.pdf | ||
| Attachment 5 - ARS 371 Construction Progress and Payment Schedule.pdf | ||
| Attachment 1 - Statement of Work.pdf | ||
| Attachment 3 - Bond Forms.pdf | ||
| Attachment 2 - Wage Determination.pdf | ||
| Attachment 6 - ARS-372 Request for Payment.pdf |
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Text version
ATTACHMENT 4
Contractor Certification Regarding Project: 12805B24 606
201 20 202 202 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 .