Contractor EMR Certification Form 2020.docx
DOCX document 15 KB Posted
- Attached to
- Y1PZ--PARKING STRUCTURE FALL PROTECTION 506-20-105 Federal contract opportunity
- Solicitation number
- 36C25020B0053
About this file
This document contains a pre-solicitation announcement and related contractor experience form for a federal construction contract opportunity. The Department of Veterans Affairs will issue an invitation for bid on June 11, 2020 for project number 506-20-105 to replace interior and exterior spandrel beam railings with fall deterrent fencing on levels C, D and E of the West Parking Structure at the VA Ann Arbor Healthcare System. The contractor will be required to remove existing railings, repair precast concrete, fabricate and install new fall deterrent fencing per VA standards and codes. The work must be completed within 150 days of contract award. The contractor must submit the included pre-award contractor experience modification rate form providing OSHA recordable incident rates and insurance experience modification rate. The North American Industry Classification for this opportunity is 236220 and the government intends to award a firm fixed price contract between $1-5 million within 120 days of bid receipt.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25020B0053 0005.docx | DOCX document | |
| Porject 506-20-105 RFI Answers.docx | DOCX document | |
| 36C25020B0053 0004.docx | DOCX document | |
| 36C25020B0053 0003.docx | DOCX document | |
| 36C25020B0053 0002_1.docx | DOCX document | |
| 36C25020B0053 0001.docx | DOCX document | |
| Wage Rates - MI2020100 Updated 7-10-2020.pdf | ||
| 506-20-105 Specifications - Revised 7-20-2020.pdf | ||
| 506-20-105 West Parking Structure Fall Protection Drawings - Revised 7-20-2020.pdf | ||
| 506-20-105 West Parking Structure Fall Protection Drawings.pdf | ||
| 506-20-105 Specifications.pdf | ||
| 36C25020B0053_1.docx | DOCX document | |
| 506-20-105 RFI Form.docx | DOCX document | |
| MI20200100 01-24-2020.pdf |
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25020B0044 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| Category |
| 2016 |
| 2017 |
| 2018 |
| 2019 |
Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations.
2. Please attach copies of the following documents: 2019 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .