Total employee hours worked Year Recordable Incidents Total Employee Hours Worked Recordable Incident Rate 1-20 2-20 3-20 Total Enter EMR for the most recent year (this information is Experience Modification Rate (EMR). Firm’s provided by compensation insurance carrier). Firm’s worker’s Year EMR Is Your Firm Self-Insured in California? No 20 Yes Self-Insured No. *Attach certification. Page intentionally left blank
Total employee hours worked Year Recordable Incidents Total Employee Hours Worked Recordable Incident Rate 1-20 2-20 3-20 Total Experience Modification Rate (EMR). Enter Firm’s EMR for the most recent year (this information is provided by Firm’s worker’s compensation insurance carrier). Year EMR Is Your Firm Self-Insured in California? 20 No Yes Self-Insured No. *Attach certification. Page intentionally left blank
FSO-2018-22-JP_CMR-EL-CENTRO-Attachment-3-Technical-Qualifications.docx