EMR Certification Form 2021-Solicitation 36C25021B0052-Project 515-20-101.docx
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- Solicitation number
- 515-20-101
About this file
This document contains a pre-award form requesting experience modification rate (EMR) information from prospective contractors for Solicitation 36C25021B0052 to renovate common areas in various buildings at the VA Medical Center in Battle Creek, Michigan. The contractor will be required to furnish all labor, materials, equipment, supervision, as-built documentation and other related information to improve conditions in several outpatient care buildings through replacement of worn ceilings, flooring, wall coverings, doors, frames and handrails along with addition of new signage and entrance vestibules at five buildings. The work must be completed within 380 days. Respondents are asked to provide EMR rates and supporting documentation from the past three years including OSHA 300 forms, as well as company safety program details.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25021B0052 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 |
| 2017 |
| 2018 |
| 2019 |
| 2020 |
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 .