Contractor EMR Certification Form .docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25022B0067
About this file
This document contains a pre-award contractor experience modification rate form and details of a related federal contract opportunity for upgrade work on domestic hot and cold-water systems at a Department of Veterans Affairs medical center. The form requests safety and insurance information from prospective contractors, including OSHA recordable incident rates, violations, and experience modification rates over the past three years. The related solicitation seeks replacement of faucets, shower valves, domestic water components, and isolation valves across five buildings. The work includes associated repairs to walls, floors, ceilings, and replacement of the domestic water supply system in one building.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Notice of Award.pdf | ||
| Project 506-19-104 Statement of Work (SOW).pdf | ||
| Project 506-19-104 Drawings.pdf | ||
| Project 506-19-104 BID SCHEDULE.docx | DOCX document | |
| Project 506-19-104 RFI Form.doc | DOC document | |
| Wage Determination MI20220100 7.15.2022.pdf | ||
| 36C25022B0067.pdf | ||
| Project 506-19-104 Project Manual.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 36C25022B0067 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 .