Experience Modification Rate EMR Insurance Contractor Certification BLANK.docx
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- Solicitation number
- 12405B23Q0590
About this file
This document contains a contractor certification template regarding a company's experience modification rate and OSHA violation history for a built-up roof replacement project. The template requires contractors to disclose the number of serious, willful, or repeat OSHA violations in the last four years and provide an explanation for any violations, as three serious, one repeat, or one willful violation would result in being deemed non-responsible. Contractors must also disclose their current insurance EMR, defined as the experience modification rate, and provide a signed letter from their insurance carrier on letterhead supporting the stated EMR. The related federal contract opportunity is for a built-up roof replacement at the headhouse portion of Building 7 issued by the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery under solicitation number 12405B23Q0590.
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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:
File details come from the government source that posted it. Updated .