Attachment B - Contractor EMR Certification Form 2022.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C24623B0011
About this file
This document contains a pre-award contractor experience modification rate form and information on a related federal contract opportunity. The form requests contact and insurance information from bidding contractors, including experience modification rates over the past three years, OSHA recordable incident rates, numbers of violations, and NAICS codes. Contractors must also provide current OSHA 300 forms and a letter from their insurance carrier stating their experience modification rate.
The related federal contract opportunity is solicitation number 36C24623B0011 from the Department of Veterans Affairs for improvements to patient privacy at phase 2 of construction project 652-21-106. Bidding contractors would be required to provide the safety and insurance experience information requested in the attached form.
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your bid applicable to Solicitation 36C24623B0011 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| Category |
| 2019 |
| 2020 |
| 2021 |
Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations.
2. Please attach copies of the following documents: a)2021 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b)Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .