S02 Contractor EMR Certification Form - 553-19-101.docx
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- Attached to
- Z1DA--Replace Parking Structures Elevators 553-19-101 Federal contract opportunity
- Solicitation number
- 36C25022B0071
About this file
This notice announces an upcoming Invitation for Bid for elevator replacement services at a Department of Veterans Affairs medical center. The solicitation will require contractors to furnish all labor, materials, equipment, and supervision to complete the replacement of elevators in two parking structures at the John D. Dingell VA Medical Center in Detroit, Michigan. Work is to be performed during normal business hours excluding federal holidays and must comply with manufacturer and industry standards. The NAICS code for this procurement is 238990 and the small business size standard is $16.5 million. The government estimates the contract value to be between $5-10 million to be awarded as a firm fixed price contract within 120 days of bid opening. This acquisition is reserved exclusively for qualified Service-Disabled Veteran-Owned Small Businesses. Interested parties should monitor the listed websites for solicitation release on or around September 9, 2022 and ensure registration in the necessary systems.
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Text version
Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25022B0071 to assist in making an initial determination of responsibility for any potential awardee in accordance with FAR 9.104-1(e) which states that “to be determined responsible, a prospective contractor must have the necessary organization, experience, accounting and operational controls, and technical skills including safety programs applicable to materials to be produced or services to be performed by the prospective contractor and subcontractors.”
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information for the past three calendar years:
| 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.
2. Please attach copies of the following documents: a) 2020 OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page: http://www.osha.gov/pls/publications/publication.html. b) Letter from insurance carrier stating current EMR rate.
3. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
4. The name and title of the person who administers your company’s Safety and Health Program? ____________________________.
5. Your company’s Insurance Experience Modification Rate (EMR): ______
File details come from the government source that posted it. Updated .