Contractor EMR Certification Form - 506-25-104.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C25026B0038
About this file
This is a Pre-Award Contractor Experience Modification Rate (EMR) Form required for Solicitation 36C25026B0038, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 for the Emergent East Parking Structure Repair project. The form is used to assess contractor responsibility in accordance with FAR 9.104-1(e) by evaluating the prospective contractor's safety record and experience.
Contractors must submit detailed occupational safety and health information covering the past three calendar years (2023, 2024, and 2025), including total man hours worked, the number of cases involving days away from work or restricted activity (DART rate), and any serious, willful, or repeat OSHA violations with explanations. Supporting documentation required includes copies of OSHA 300 and 300a Forms for 2020 and a letter from the contractor's insurance carrier stating the current EMR rate. Contractors must also provide their six-digit NAICS code applicable to the acquisition, identify the person responsible for administering the company's safety and health program, and disclose their current Insurance Experience Modification Rate (EMR).
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25026B0038 0004.docx | DOCX document | |
| 36C25026B0038 0003.docx | DOCX document | |
| S04 Pre-Bid Site Visit Agenda - 506-25-104 and Sign-in Sheet.pdf | ||
| 36C25026B0038 0002.docx | DOCX document | |
| 36C25026B0038 0001.docx | DOCX document | |
| Wage Determination MI20260100 1.02.2026.pdf | ||
| ATTACHMENT VAAR 852.219-75 DEVIATION Jan 2023 LIMITATIONS OF SUBCONTRACTING COMPLIANCE CERTIFICATION.docx | DOCX document | |
| 506-25-104 Ann Arbor Emergent Garage Repair Revised Drawings R3.pdf | ||
| RFI Form - 506-25-104.doc | DOC document | |
| 506-25-104 Ann Arbor Emergent Garage Repair Revised Bid Specifications R3.pdf | ||
| 36C25026B0038_1.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 36C25026B0038 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 .