EMR Rating Certification Form.docx
DOCX document 16 KB Posted
- Attached to
- N059--Replace Damaged Electrical Wires for VA Livermore Federal contract opportunity
- Solicitation number
- 36C26125R0023
About this file
This document is a contractor certification form for safety and environmental records related to a VA Livermore electrical wiring replacement project (Solicitation #36C26125R0023). The form requires contractors to certify they meet two key eligibility criteria: 1) having no more than three serious violations, one repeat violation, or one willful OSHA/EPA violation in the past 3 years, and 2) maintaining an Experience Modification Rate (EMR) of 1.0 or less.
Contractors must provide self-certification on company letterhead regarding their OSHA/EPA violation history and submit current EMR documentation from their insurance carrier. If a contractor's EMR exceeds 1.0, they must provide a written explanation from their insurance carrier detailing the reasons and expected timeline for reduction below 1.0. The form includes spaces to report violations for 2022-2024 and requires an authorized signature.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| S02 - RFI Responses - 36C26125R0023_2.docx | DOCX document | |
| 01 42 19 Reference Standards.docx | DOCX document | |
| S02 - 36C26125R0023 - Final.pdf | ||
| 26 05 11 Requirements for Electrical Installations.docx | DOCX document | |
| 01 32 16 17 Project Schedules.docx | DOCX document | |
| 36C26125R0023_1.docx | DOCX document | |
| DIVISIONAL COST BREAK.docx | DOCX document | |
| 01 35 26 SAFETY REQUIREMENTS.docx | DOCX document |
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Text version
Contractor Certification Regarding Project:
To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) in the past 3 years and have an EMR of equal to or less than 1.0.
All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their offer.
1. SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the contractor has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.
2. EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offerors’s insurance carrier and be furnished on the insurance carrier’s letterhead. If an Offeror’s EMR is above 1.0, Offeror shall submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
| 2022 |
| 2023 |
| 2024 |
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 disqualifies the contractor.)
Number of violations from EPA within the last 3 years. Please attach explanation for any violations.
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:
Print Name: _________________________________________________
File details come from the government source that posted it. Updated .