Contractor EMR Certification Form - 506-24-102.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C25026B0028
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Form required for solicitation 36C25026B0028, an elevator upgrade project at a Department of Veterans Affairs facility (Z1DA--Upgrade Elevators 506-24-102). The form is used to assess prospective contractor responsibility in accordance with FAR 9.104-1(e) by evaluating organizational experience, controls, technical skills, and safety programs.
Contractors must submit detailed safety and workers' compensation information including three years of OSHA 300 Form data (man hours, DART rates, and violation history), copies of their 2020 OSHA 300 and 300a Forms, and a letter from their insurance carrier stating their current EMR rate. Additionally, contractors must provide their six-digit NAICS code, identify the person administering their company's Safety and Health Program, and disclose their company's Insurance Experience Modification Rate. This template is used as an evaluation tool rather than a substantive product or service specification document.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25026B0028 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 |
| 2023 |
| 2024 |
| 2025 |
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) 2020 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 .