Contractor EMR Certification Form 2021.docx
DOCX document 15 KB Posted
- Attached to
- Z1DA--Modernize Hospital Finishes 506-20-204
- Solicitation number
- 36C25021B0037
About this file
This document contains a pre-award form for a contractor seeking qualification for a hospital finishes renovation project and the related federal contract opportunity solicitation. The pre-award form requests experience modification rate (EMR) information from insurance carriers to evaluate the contractor's safety programs and history. It asks for OSHA recordable incident rates over the past three years, copies of OSHA forms, the contractor's NAICS code, and insurance EMR. The related solicitation is for modernizing finishes in corridors at the Ann Arbor VA Medical Center, including new flooring, walls, handrails and wayfinding over 4,793 square feet to be completed in phases. The work must comply with manufacturer and code requirements and be performed without disrupting medical operations between 6pm-5:30am Monday through Sunday, with construction areas accessible during normal business hours. The contractor must provide barriers, dust partitions, walk-off mats if needed, on-site cleaning, and dumpsters. Shop drawings must be submitted for approval.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25021B0037 0002.docx | DOCX document | |
| S04 - Sign-In Sheet Pre-Bid 506-20-204 4-28-2021.pdf | ||
| S04 - Pre-Bid Site Visit Agenda 506-20-204.pdf | ||
| 36C25021B0037 0001.docx | DOCX document | |
| Wage determination MI20210100 - 2-26-2021.pdf | ||
| 506-20-204 Drawings.pdf | ||
| 506-20-204 Project Specifications.pdf | ||
| FINAL 506-20-204 Modernize Hospital Finishes SOW.pdf | ||
| 36C25021B0037.docx | DOCX document | |
| RFI Form 506-20-204.docx | DOCX document |
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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 36C25021B0037 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 |
| 2017 |
| 2018 |
| 2019 |
| 2020 |
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: a)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. b)Letter from insurance carrier stating current EMR rate.
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 .