Attachment 11: Bonding Requirements and Safety Record Bonding Requirements: Provide your original Proof of Bonding Letter in accordance with the requirements of Section 3.0 F of this RFP. Safety Record: In the case of a joint venture submission, include all information required below, for each parent company if the joint venture entity does not have at least a three (3) year experience base. Respond to the following question: Has the Contractor, or any officer of the Contractor or any employee of the Contractor who has a proprietary interest in the making of this Proposal, ever been disqualified, removed, or otherwise prevented from bidding on or completing any federal, or local governmental project because of a violation of law or safety regulations: No Yes If your answer is yes, explain the circumstances here: A. Attach a copy of the company’s OSHA Form 300 Log and Summary of Occupational Injuries and Illnesses – for the past two (2) calendar years. B. Recent Incidence Data: Complete this or attach one with the same format. Following OSHA reporting guidelines, provide incidence data for the two (2) most recently completed projects listed under. A B C D E F G INCIDENCE INCIDENCE INCIDENCE RATE FOR RATE FOR RATE FOR BY INJURIES ILLNESSES LOST DAYS DAYS WORK WORK WORK TOTAL (A)x(200,000) (B)x(200,000) (C)x(200,000) HOURS OF OF TO RELATED RELATED OF COMPANY INJURIES WORKED (D) (D) (D) # # LOST (CONVERT EMPLOYEES ILLNESSES PROJECT #1: PROJECT #2: COMPANY TOTALS
Attachment 11: Bonding Requirements and Safety Record Bonding Requirements: Provide your original Proof of Bonding Letter in accordance with the requirements of Section 3.0 F of this RFP. Safety Record: In the case of a joint venture submission, include all information required below, for each parent company if the joint venture entity does not have at least a three (3) year experience base. Respond to the following question: Has the Contractor, or any officer of the Contractor or any employee of the Contractor who has a proprietary interest in the making of this Proposal, ever been disqualified, removed, or otherwise prevented from bidding on or completing any federal, or local governmental project because of a violation of law or safety regulations: No Yes If your answer is yes, explain the circumstances here: A. Attach a copy of the company’s OSHA Form 300 – Log and Summary of Occupational Injuries and Illnesses for the past two (2) calendar years. B. Recent Incidence Data: Complete this or attach one with the same format. Following OSHA reporting guidelines, provide incidence data for the two (2) most recently completed projects listed under. A B C D E F G # OF WORK RELATED INJURIES # OF WORK RELATED ILLNESSES LOST DAYS OF WORK (CONVERT TO TOTAL HOURS WORKED BY COMPANY EMPLOYEES INCIDENCE RATE FOR INJURIES (A)x(200,000) (D) INCIDENCE RATE FOR ILLNESSES (B)x(200,000) (D) INCIDENCE RATE FOR LOST DAYS (C)x(200,000) (D) PROJECT #1: PROJECT #2: COMPANY TOTALS
OREFM-2013-JMG-04-Fillable-Forms-and-Instructions.docx