Experience Modification Rate Form 2026 Revised 2 2 2026.pdf
PDF 163 KB Posted
- Solicitation number
- 36C24726R0039
About this file
This is an Experience Modification Rate Form template that offerors must complete and submit with their response to the solicitation.
The form requires companies to provide their company name, address, telephone, email, and contact person, followed by OSHA safety and workers' compensation data. In Section 1, offerors must complete a table for calendar years 2024, 2025, and 2026 that includes: the total number of man hours worked at jobsites and offices; the number of cases involving days away from work, restricted activity, or both (from OSHA 300 Form columns H and I); the calculated Days Away, Restricted, or Transferred (DART) rate using the formula of (number of cases × 200,000 ÷ number of man hours); and the number of serious, willful, or repeat OSHA violations within the past three years with explanations for any violations. The form specifies that contractors with four serious violations, one repeat violation, or one willful violation are disqualified. Offerors must attach copies of their OSHA 300 and 300a Forms, which are available through the OSHA publications search page. In Section 2, offerors must provide their company's Insurance Experience Modification Rate (EMR) for the past three years. The government will use the submitted information along with data from OSHA and EPA online inspection history databases to verify that contractors meet the Experience Modification Rate requirement specified in the solicitation.
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Text version
Attachment 1 Experience Modification Rate Form
Offeror To Complete & return with response to solicitation
Company Name: ______________________________________________________________________
Address: _____________________________________________________________________________
Telephone: _______________________ Email: _____________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2024 2025 2026 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. (Four serious, one repeat, or one willful disqualifies the contractor.)
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
2. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years :
The above information, along with other information obtained from Government systems, such as the OSHA and EPA online inspection history databases will be used to ensure the contractor meets Experience Modification Rate indicated in the solicitation.
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .