Experience_Modification_Rate_(EMR)_7245.docx

Jet Propulsion Laboratory California Institute of Technology Experience Modification Rate (EMR)/ Recordable Incident Rate / Lost-Time Incident Rate (ITB/RFP Attachment B-18)

This form must be completed and submitted to JPL. The intent of this form is to measure and evaluate each Subcontractor’s frequency, severity, and incident rates as they relate to workers compensation insurance claims. The EMR (Experience Modification Rate) is a number established by insurance carriers to accurately adjust an individual company’s workers compensation insurance premiums based on industry average workers compensation insurance claims for their respective NAICS (North American Industry Classification System). Recordable and lost-time incident rates are used to measure and evaluate a company’s frequency, severity, and incident rates as they relate to occupational related injuries and illnesses. In addition to the information provided below, please attach copies of your OSHA 300, 301, and 300A forms for each of the three respective years.

General Information (type in)

Subcontractor Name:

Date:

Project Name:

ITB/Subcontract No:

NAICS / SIC No.:

Have an EMR? |_| Yes |_| No

Recordable Injuries / Illnesses Data

worked

Incident Rate

Year 1:

Year 2:

Year 3:

Loss-Time Injuries / Illnesses Data

worked

Work Days Lost-Time Incident Rate

Year 1:

Year 2:

Year 3:

Workers Compensation EMR (Experience Modification Rate)

Year 1:

Year 2:

Year 3:

Rate:

Rate:

Rate:

Approval

Authorized Representative Signature:

Date:

Type/Print Name:

Type/Print Title:

JPL 7245-B18, 2/14

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