Contractor EMR Certification Form .docx
DOCX document 15 KB Posted
- Attached to
- Y1DA--Correct Deficiencies 1W sub-basement 506-21-210 Federal contract opportunity
- Solicitation number
- 36C25022B0058
About this file
This document contains a pre-award contractor experience modification rate form and details for a federal solicitation to correct deficiencies in the 1W sub-basement at the Ann Arbor VA Medical Center. The form requests contact information and safety data from the past three years, including total man hours, OSHA recordable cases, days away from work rates, and any serious violations. It also requires copies of 2019-2021 OSHA forms, the company's current EMR rate from its insurance carrier, the NAICS code for the work, and the name of the safety program administrator. The related solicitation is for a contractor to prepare the site and furnish all labor, materials, and work to complete additions and renovations for the project at the specified VA location according to provided drawings and specifications.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Notice of Award.pdf | ||
| Project 506-21-210 Specifications Updated.pdf | ||
| Project 506-21-210 Drawings Updated.pdf | ||
| 36C25022B0058 Amendment 0001.pdf | ||
| RFI Form Solicitation.doc | DOC document | |
| BID SCHEDULE.docx | DOCX document | |
| Project 506-21-210 Drawings.pdf | ||
| Project 506-21-210 Specifications.pdf | ||
| Project 506-21-210 Statement of Work (SOW).pdf | ||
| 36C25022B0058.pdf | ||
| Wage Determination MI20220100 7-15-22.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 36C25022B0058 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 |
| 2019 |
| 2020 |
| 2021 |
| 2022 |
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 .