Contractor Certification Regarding Safety and Environmental.docx

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Attached to
Z1DA--Remodel Building 97 610-20-517 Federal contract opportunity
Solicitation number
36C25020B0079
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10

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Contractor Certification Regarding Project: 610-20-517

2017
2018
2019

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: ______________________________________________________

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