EMR Certification.docx

13 KB Posted

Attached to
Replace Drain Pipe and Repair Road at Log Lodge
Solicitation number
12305B21R0039
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Contractor Certification Regarding Project: Project Title Here

2015
2016
2017
2018

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: ______________________________________________________

File details come from the government source that posted it. Updated .