S02 Contractor EMR Certification Form - 553-23-100.pdf
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- Attached to
- Z1DA--Thermo Storage Tank Repairs 553-23-100
- Solicitation number
- 36C25024B0010
About this file
This document is a pre-award contractor experience modification rate form for solicitation 36C25024B0010 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 for repairs to thermo storage tanks. Potential awardees must provide safety program and insurance documentation including OSHA 300 forms from the past three years, current EMR rate from their insurance carrier, NAICS code, safety program administrator contact information, and explanation for any OSHA violations. Copies of current OSHA 300 and 300a forms must be attached. The solicitation number, agency, and opportunity type are provided for reference.
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Pre-Award Contractor Experience Modification Rate (EMR) Form
Information regarding your EMR is being sought in conjunction with your offer applicable to Solicitation 36C25024B0010 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 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)2023 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): ______ http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .