CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.doc

DOC document 9 KB Posted

Attached to
Y1DA--Mental Health EOC Compliance Federal contract opportunity
Solicitation number
36C26121R0072
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

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This document contains a contractor certification form regarding safety and environmental compliance for a federal solicitation. The certification form requires contractors to disclose the number of serious, willful, or repeat OSHA violations in the last 3 years and provide an explanation for any violations, as more than one of certain types of violations would disqualify the contractor from consideration. The contractor must also disclose its current insurance Experience Modification Rate and provide supporting documentation from its insurance carrier.

The related federal contract opportunity is solicitation number 36C26121R0072 for projects 654-20-141 and 654-17-713 regarding inpatient mental health EOC compliance and door frames/doors. The soliciting agency is the Department of Veterans Affairs Veterans Health Administration VISN 21.

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CONTRACTOR CERTIFICATION REGARDING SAFETY AND

ENVIRONMENTAL Contractor Certification Regarding Project: 654-20-141

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 disqualifies the contractor.)

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 .