Contractor Certification Regarding EMR.pdf
PDF 106 KB Posted
- Attached to
- Replace Main Distribution Panel and Associated Electrical Feeders Federal contract opportunity
- Solicitation number
- 1232SA25R0033
About this file
This document is a Contractor Certification form for documenting OSHA violations and Insurance Experience Modification Rate (EMR) for a specific project. The form requires contractors to report the number of serious, willful, or repeat OSHA violations from 2020-2023, noting that four serious, one repeat, or one willful violation could result in being deemed non-responsible. Contractors must also provide their current EMR and support it with a signed letter from their insurance carrier. The form includes signature lines for the contractor's typed name, signature, and title, allowing for formal documentation of safety and insurance compliance for the referenced project.
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| File | Type | Posted |
|---|---|---|
| Site Visit Sign-In 07152025.pdf | ||
| RFIs.pdf | ||
| Site Visit Sign-In 07162025.pdf | ||
| SF30 - Amendment 01.pdf | ||
| SF-1442.pdf | ||
| Wage Determination.pdf | ||
| Calculation of Self-Performed Work.pdf | ||
| ARS-371.pdf | ||
| Past Performance Questionnaire.pdf | ||
| Statement of Work and Specifications.pdf | ||
| Drawings.pdf | ||
| ARS-372.pdf |
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Text version
Contractor Certification Regarding Project: Project Title Here
2020 2021 2022 2023
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 .