Attachment 5 - Contractor Certification Regarding EMR.docx

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Attached to
NCSL Greenhouse Renovation PH III
Solicitation number
12805B24R0013
Issued by

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Contractor Certification Regarding Project: 12805B24R0013

2020
2021
2022
2023

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:

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