Experience Modification Rate EMR Insurance Contractor Certification BLANK.docx
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- Solicitation number
- 12405B23Q0237
About this file
This solicitation is seeking quotations for the installation of new roofing systems on three buildings at research facilities in Athens, Georgia. The Department of Agriculture Agricultural Research Service is requesting roofing installation services for Building 13 North and South, Building 15 North and South, and Building 2 Maintenance Shop. Interested contractors must visit the site by May 25th to confirm project details. Questions about the solicitation are due by May 31st and quotations must be submitted by June 5th. Responses must include forms SF1442, SF24, and an EMR certification form. The project value is between $250,000 and $500,000. This is a total small business set-aside with a NAICS code of 238160. The solicitation references standard FAR clauses for commercial item contracts.
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Text version
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:
File details come from the government source that posted it. Updated .