S02 Contractor EMR Certification Form - 553-21-105.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C25025B0004
About this file
This is a contractor Experience Modification Rate (EMR) certification form required for Solicitation 36C25025B0004, a parking garage repair project at the John D. Dingell VA Medical Center in Detroit. The form requires contractors to provide safety performance data including OSHA 300 statistics for 2021-2023, current EMR rates, and documentation of any OSHA violations.
The associated solicitation is a 100% SDVOSB set-aside with an estimated value between $2-5 million for repairing deficiencies in two parking structures (Buildings 101 and 102). The scope includes concrete repairs, structural improvements, and corrosion prevention while maintaining operations with a maximum of 500 parking spaces removed at any time. The period of performance is 305 calendar days, with award expected within 120 days of bid opening. The work falls under NAICS code 236220 with a $45 million size standard.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25025B0004 0004.docx | DOCX document | |
| 36C25025B0004 0003.docx | DOCX document | |
| S04 Pre Bid Site Visit Attendance Log - Complete - 553-21-105.pdf | ||
| 36C25025B0004 0002.docx | DOCX document | |
| 36C25025B0004 0001.docx | DOCX document | |
| 36C25025B0004_1.docx | DOCX document | |
| S02 RFI Form - 553-21-105.doc | DOC document | |
| Drawings Project - 553-21-105.pdf | ||
| Specification Project - 553-21-105.pdf | ||
| S02 Wage Determination - MI 20240101 - 553-21-105.pdf |
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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 36C25025B0004 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 |
| 2021 |
| 2022 |
| 2023 |
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 .