S02 Atch E Safety or Environmental Violations and EMR Information - 2 pages.pdf
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- Solicitation number
- 36C26326B0021
About this file
This document is a pre-award contractor safety and environmental record evaluation form and requirements specification for federal contract solicitations.
All bidders and offerors must submit comprehensive safety and environmental compliance documentation as part of the responsibility determination process. Bidders must disclose any OSHA or EPA violations occurring within the past three years, specifically identifying instances of more than three serious violations, one or more repeat violations, or one or more willful violations, with written explanations required for each violation cited. Regarding Experience Modification Rate (EMR), bidders must obtain current EMR information from their insurance carrier on carrier letterhead; if the EMR exceeds 1.0, bidders must provide a written explanation from the insurance carrier describing the reasons for the elevated rating and anticipated timeline for reduction to 1.0 or below. Self-insured contractors unable to obtain EMR ratings from standard insurance carriers must complete NCCI form ERM-6 and provide ratings on NCCI letterhead, with exceptions for contractors in CA, DE, MI, NJ, ND, OH, PA, WA, WY, and PR, who must obtain ratings from their respective state-run workers' compensation insurance rating bureaus. For new contractors lacking insurance history, NCCI must issue a Unity Rating of 1.0, documented with letters from both the insurance carrier and NCCI. The evaluation form requires completion of OSHA 300 and 300a forms covering 2023 through 2025, including man hours, injury case counts, DART rates, and documentation of serious, willful, or repeat OSHA violations. Prime contractors bear responsibility for determining subcontractor responsibility at all tiers. Information gathered from government databases, including OSHA and EPA online inspection histories, will inform the initial determination of responsibility.
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FOR OFFICAL USE ONLY 1 of 2
Safety or Environmental Violations and Experience Modification Rating Information
1. All Bidders/Offerors shall submit information pertaining to their past Safety and
Environmental record. The Bidders/Offerors needs to explain if they have more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years.
2. All Bidders/Offerors shall submit information regarding their current Experience Modification Rate (EMR). This information shall be obtained from the Bidder’s/Offeror’s insurance carrier and be furnished on the insurance carrier’s letterhead. If a Bidder/Offeror’s EMR is above 1.0, Bidder/Offeror must submit a written explanation of the EMR from its insurance carrier furnished on the insurance carrier’s letterhead, describing the reasons for the elevated EMR and the anticipated date the EMR may be reduced to 1.0 or below.
3. Self-insured contractors or other contractors that cannot provide their EMR rating on insurance letterhead must obtain a rating from the National Council on Compensation Insurance, Inc. (NCCI) by completing/submitting form ERM-6 and providing the rating on letterhead from NCCI. Note: Self-insured contractors or other contractors that cannot provide EMR rating on insurance letterhead from the states or territories of CA, DE, MI, NJ, ND, OH, PA, WA, WY, and PR shall obtain their EMR rating from their state-run worker’s compensation insurance rating bureau.
4. If the NCCI cannot issue an EMR because the Bidder/Offeror lacks insurance history, Bidder/Offeror shall submit a letter indicating so from its insurance carrier furnished on the insurance carrier’s letterhead and include a letter from the NCCI indicating that is has assigned Bidder/Offeror a Unity Rating of 1.0.
5. 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 make an initial Determination of Responsibility.
6. This requirement is applicable to all subcontracting tiers, and prospective prime contractors are responsible for determining the responsibility of their prospective subcontractors.
FOR OFFICAL USE ONLY 2 of 2
PRE-AWARD CONTRACTOR SAFETY AND ENVIRONMENTAL RECORD
EVALUATION FORM
Information provided below is current and applicable to Solicitation:
Company Name: ___________________________________________________________ Address:
Telephone: Fax:
Email:
Contact:
Utilizing the completed OSHA 300 Forms, please complete the table below:
Category 2023 2024 2025 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.
Please attach copies of the following documents: OSHA 300 (Log of Work-Related Injuries and Illnesses) and 300a Forms (Summary of Work-Related Injuries and Illnesses).
These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html.
1. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: 238220
2. Who administers your company’s Safety and Health Program?
3. Company’s Insurance Experience Modification Rate (EMR):
http://www.osha.gov/pls/publications/publication.html
PRE-AWARD CONTRACTOR SAFETY AND ENVIRONMENTAL RECORD EVALUATION FORM
File details come from the government source that posted it. Updated .