Contractor Certification Regarding EMR.pdf
PDF 127 KB Posted
- Attached to
- Soft Water / RO System Federal contract opportunity
- Solicitation number
- 12905B20R0016
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Text version
Contractor Certification Regarding Project:
Year
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: ______________________________________________________
Contractor Certification Regarding Project:
| Companys Current Insurance Experience Modification Rate EMR: |
| Typed Name: |
| Title: |
| Year: 2016 |
| Year1: 2017 |
| Year2: 2018 |
| Year3: 2019 |
| OSHA within the last 3 years Please attach explanation: |
| OSHA within the last 3 years Please attach explanation1: |
| OSHA within the last 3 years Please attach explanation2: |
| OSHA within the last 3 years Please attach explanation3: |
| Text1: |
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