EMR Certification.docx

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Attached to
Log Lodge Bldg 302 Restrooms Renovation
Solicitation number
12305B22R0027
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Contractor Certification Regarding Project: Project Title Here

2018
2019
2020
2021

Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful violation could result in being determined non-responsible.)

Company’s Current Insurance Experience Modification Rate (EMR) = _____________ (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature: ______________________________________________

Typed Name: ______________________________________________________

Title: ______________________________________________________

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