Contractor Certification Regarding EMR.docx

DOCX document 13 KB Posted

Attached to
Resolve HVAC Issues in Building 15 Federal contract opportunity
Solicitation number
36C25020B0031
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10

About this file

This document contains a federal contract solicitation and related contractor certification form. The solicitation is for resolving HVAC issues in Building 15 at the Veterans Administration Indianapolis facility. The solicitation number is 36C25020B0031. The project magnitude is between $100,000 and $200,000. The solicitation is a 100% set-aside for service-disabled veteran-owned small businesses under NAICS code 236210 with a size standard of $15 million. Interested contractors must register on SAM.gov and VetBiz.gov. The contractor certification form requires disclosure of any OSHA or EPA violations in the past three years and the current experience modification rate. The proposal due date will be approximately 30 days after the solicitation is posted on July 15, 2018. The contract duration is 365 calendar days from notice to proceed. Performance and payment bonds will be required.

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Text version

Contractor Certification Regarding Project: 539-20-212

2016
2017
2018
2019

Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful violation could 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 .