Contractor Certification Regarding EMR.pdf
PDF 106 KB Posted
- Attached to
- Fencing and Concrete Foundation Replacement
- Solicitation number
- 1232SA25R0010
About this file
The document is a Contractor Certification form related to a federal contract opportunity for fencing and concrete foundation replacement. The form requires contractors to disclose their Occupational Safety and Health Administration (OSHA) violations over the past four years, noting that four serious, one repeat, or one willful violation could result in being deemed non-responsible. Contractors must also provide their current Insurance Experience Modification Rate (EMR) supported by a signed letter from their insurance carrier. The form includes fields for the contractor's signature, typed name, and title, with space to document OSHA violations for the years 2020-2023.
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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 .