S02 Contractor Certification RE Safety and EMR.pdf
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- Solicitation number
- 36C26125R0071
About this file
This document is a Contractor Certification form for safety and environmental compliance related to the McClellan Bldg. 98 Power Upgrade project (612A4-24-004). Per VHA Directive 7715, contractors must meet specific safety requirements to be eligible for contract consideration, including having no more than three serious, one repeat, or one willful OSHA or EPA violations within the past three years, and maintaining an Experience Modification Rate (EMR) of 1.0 or less. Offerors are required to submit a self-certification on company letterhead detailing their safety and environmental record, including a table documenting violations from OSHA and EPA for the years 2022-2024, along with a signed letter from their insurance carrier verifying their current EMR.
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CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL
Contractor Certification Regarding Project: 612A4-24-004 McClellan Bldg. 98 Power Upgrade
PER VHA DIRECTIVE 7715 (06 April 2017): SAFETY & ENVIRONMENTAL RECORD AND EXPERIENCE MODIFICATION RATE (EMR): To be eligible for consideration and award, the contractor shall have no more than three serious, or one repeat, or one willful OSHA or EPA violation(s) within the past 3 years and have an EMR of equal to or less than 1.0.
All Offerors shall submit the following information pertaining to their past Safety & Environmental Record and EMR with their bid/proposal:
SAFETY & ENVIRONMENTAL RECORD: A self-certification on company letterhead that the Offeror has no more than three (3) serious, or one (1) repeat or one (1) willful OSHA or any EPA violation(s) within the past three years. Include the following table and signature block.
2022 2023 2024
Number of serious, willful, or repeat violations from OSHA within the last 3 years.
Number of serious, willful, or repeat violations from EPA within the last 3 years
Signature: ______________________________________________
Typed Name: ______________________________________________________
Title: ______________________________________________________
EMR: All Offerors shall submit information regarding their current EMR. This information shall be obtained from the Offeror’s insurance carrier and be furnished on the insurance carrier’s letterhead.
Contractor’s Current Insurance Experience Modification Rate (EMR) = _____________
(Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)
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