Experience Modification Rate EMR Insurance Contractor Certification BLANK.docx

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Attached to
Demolish/Dispose Building 6 (Greenhouse 30)
Solicitation number
12405B23Q0130
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EXPERIENCE MODIFICATION RATE (EMR) CERTIFICATION

Contractor Certification Regarding Project:

2019
2020
2021
2022

Number of serious, willful, or repeat violations from OSHA within the last 4 years. Please attach explanation for any violations. (Three serious, one repeat, or one willful violation shall 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:

Company Name: ____________________________________________

Title:

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