S02 - Attachment - 4 - EMR (1 Page) BLD 7.docx
DOCX document 14 KB Posted
- Solicitation number
- 36C24824R0103
About this file
This document is an EMR (Experience Modification Rate) Pre-Award Contractor Evaluation Form that bidders/offerors must complete and submit with their proposals for the federal contract opportunity to "Replace Roof Building 7 at Miami VA Medical Center".
The key details are:
- Bidders/offerors must provide their OSHA 300 data for the past 3 years, including number of man hours, days away/restricted/transferred cases, and DART rate. They must also report any OSHA violations in the past 3 years.
- Bidders/offerors must provide their 6-digit NAICS code and identify who administers their safety and health program.
- Bidders/offerors must provide their company's Insurance Experience Modification Rate (EMR) for the past 3 years, as an EMR greater than 1.0 disqualifies the contractor.
- The related federal contract opportunity is Solicitation Number 36C24824R0103 to "Replace Roof Building 7 at Miami VA Medical Center" for the Department of Veterans Affairs. The site visit is on 3/26/2024 and RFIs are due by 3/29/2024.
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Text version
EMR FORM FOR BIDDER/OFFEROR TO COMPLETE & SUBMIT WITH PROPOSAL
Pre-Award Contractor Evaluation Form Company Name: ______________________________________________
Address: _____________________________________________________
Telephone: ______________________ Fax: ________________________
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. (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. 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): _____________
File details come from the government source that posted it. Updated .