Attachment 5 - Contractor Certification Regarding EMR.docx

This document is a contractor certification form regarding safety violations and insurance experience modification rates that must be completed and submitted in response to Solicitation Number 12305B23R0019 from the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Northeast Area to replace and upgrade underground steam and condensate piping. The form requires contractors to disclose the number of serious, willful, or repeat occupational safety violations from OSHA in the last three years and provide an explanation for any violations, as four serious, one repeat, or one willful violation could result in a determination of non-responsibility. Additionally, contractors must disclose their current insurance experience modification rate and provide a signed letter from their insurance carrier on letterhead supporting the provided rate. An authorized representative of the contractor must sign and provide their name and title on the certification form.