Contractor Certification Regarding EMR.pdf
PDF 106 KB Posted
- Attached to
- Replace Exhaust System and Air Handling Units Federal contract opportunity
- Solicitation number
- 1232SA25R0013
About this file
The document is a Contractor Certification form for documenting Occupational Safety and Health Administration (OSHA) violations and Insurance Experience Modification Rate (EMR). The form requires contractors to disclose the number of serious, willful, or repeat OSHA violations from 2020-2023, with a warning that four serious, one repeat, or one willful violation could result in being determined 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 the company to certify their safety record for a specific project.
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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 .