CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.docx

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Z2FB--NRM 640-24-116 | Repair Aquatic Center, Palo Alto Bldg 530
Solicitation number
36C26124R0053
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This document is a Contractor Certification Regarding Safety and Environmental compliance for a federal contract opportunity. The contractor must provide information on any serious, willful, or repeat OSHA violations within the last 3 years, as well as their current Insurance Experience Modification Rate (EMR). No more than four serious, one repeat, or one willful violation is allowed. The contractor must also provide a signed letter from their insurance carrier supporting the EMR.

The related federal contract opportunity is Solicitation Number 36C26124R0053 to repair the Palo Alto Aquatic Center (Building 530), including HVAC, concrete, pool equipment electrical, drywall, mold mitigation, and plumbing. The work is to be performed in 2020 through 2023. A site visit is scheduled for June 11, 2024, RFIs are due by June 20, 2024, and proposals are due by July 1, 2024. All questions and proposals should be emailed to samantha.henderson@va.gov. The contracting agency is the Department of Veterans Affairs Veterans Health Administration, Veterans Integrated Service Network 21.

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CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL

Contractor Certification Regarding Project: 640-24-116 Repair Aquatic Center Bldg 530

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 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 .