Contractor Certification Regarding EMR.pdf

PDF 127 KB Posted

Attached to
Laboratory Remodel Kimberly ID Federal contract opportunity
Solicitation number
12905B21Q0007
Issued by
Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Pacific West Area

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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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