S02 - Attachment 02 - Contractor Safety and EMR (2 pages).pdf
PDF 87 KB Posted
- Attached to
- Z2DA--Replace Self Closing Doors at MICU and CCU Federal contract opportunity
- Solicitation number
- 36C24824R0088
About this file
This document contains a solicitation attachment requesting safety and environmental record information from bidders. The attachment requires bidders to certify having no more than three serious or one repeat or willful OSHA or EPA violations in the past three years, and to provide explanations for any violations. It also requires bidders to submit their current Experience Modification Rate from their insurance carrier on carrier letterhead, including explanations for rates above 1.0. Bidders must provide their NAICS code, safety program administrator contact information, and OSHA 300 and 300A forms. The related federal contract opportunity is for replacing self-closing doors at the MICU and CCU units of the VA Caribbean Healthcare System in San Juan, Puerto Rico, set aside for Service-Disabled Veteran-Owned Small Businesses.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24824R0088 0002 RFIs Reponses.docx | DOCX document | |
| 36C24824R0088 0001 (Exend due date).docx | DOCX document | |
| S02 - Attachment 06 - Subcontractor Past Performance Consent Form (2 Pages).pdf | ||
| S02 - Attachment 04 - Letter of Commitment Key Subcontractors (1 Page).pdf | ||
| 36C24824R0088 (BB 672-24-123) Replace Self Closing Doors.docx | DOCX document | |
| S02 - Attachment 03 - Specialized Experience Form (3 Pages).pdf | ||
| S02 - Attachment 01 - Specifications 08342 (5 Pages).pdf | ||
| S02 - Attachment 05 - Past Performance Questionnaire (4 Pages).pdf |
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Text version
Solicitation Attachment 03
Safety or Environmental Violations and Experience Modification Rate (EMR)
All Bidders/Offerors shall submit information pertaining to their past Safety and Environmental record.
The information must contain a certification that the bidder/offeror has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) in the past three years. If such certification cannot be made, a Bidder/Offeror shall explain why and submit as much information as possible regarding the circumstances of its past safety and environmental record, including the number of EPA violations and/or the number of serious, repeat, and/or willful OSHA violations, along with a detailed description of those violations.
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 EMR, and the anticipated date the EMR may be reduced to 1.0 or below.
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.
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.
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.
This requirement is applicable to all subcontracting tiers, and prospective prime contractors are responsible for determining the responsibility of their prospective subcontractors.
Solicitation Attachment 03
Safety or Environmental Violations and Experience Modification Rate
Pre-Award Contractor Safety and Environmental Record Evaluation Form
Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________
Email: _______________________________________________________
Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2020 2021 2022
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 and 300a Forms. These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
2. Provide your six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of greater than 1.0 disqualifies the contractor): _____________ http://www.osha.gov/pls/publications/publication.html
| Solicitation Attachment 03 |
| Safety or Environmental Violations and Experience Modification Rate (EMR) |
| Solicitation Attachment 03 |
| Safety or Environmental Violations and Experience Modification Rate |
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