Contractor Certification Regarding Safety and Environmental.docx

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Upgrade Signage and Wayfinding, Project 610A4-22-208
Solicitation number
36C25024B0003
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This document contains a contractor certification form and details of a related federal contract opportunity for upgrade signage and wayfinding services. The contractor certification form requests company information including the number of any serious, willful, or repeat OSHA violations in the last three years and the current insurance EMR rating, to be supported by a letter from the contractor's insurance carrier.

The related federal contract opportunity is solicitation number 36C25024B0003 to provide all supervision, labor, materials, and equipment for replacing exterior and interior signage and installing banners at the Veterans Health Administration campus in Fort Wayne, Indiana. The requirement includes replacing post-mounted parking and campus signs, panel signs, informational signs, and building-mounted signs, as well as repairing landscaping and installing banners on light poles as needed. The contracting agency is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10.

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Contractor Certification Regarding Project: 610A4-22-208

2020
2021
2022

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 .