Contractor Certification Regarding EMR.pdf

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Attached to
Install Shade Structures over GOV Parking Lot
Solicitation number
12905B21R0012
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Contractor Certification Regarding Project: TBD

2017 2018 2019 2020 Number of serious, willful, or repeat violations from OSHA within the last 4 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: TBD

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