SECTION 5 SAFETY RECORD – 1. List your firm’s Workers Compensation Experience Modification Rate (EMR) for the three (3) most recent years. Your EMR should be obtained from your insurance agent. Please attach letter from the insurance agent/carrier identifying the EMR rate for the past three years and also indicating your current EMR rate. 2015 2016 2017 as of 2. Please provide actual information in all boxes Do not enter the points! Points will – be calculated based on entries. For District Use 2015 2016 2017 Only Workers Compensation Experience Modification Rate (EMR) _____ Pts. <1= 10 pts, 1.1–1.4 = 5 pts, >1.5 = 0 pts Number of fatalities _____ 1 or more = 0 pts, 0 = 5 pts Pts. OSHA Violations _____ <0=5 pts, 1-2 = 3 pts, >2 = 0 pts Pts. _____ TOTAL POINTS Pts.
SECTION 5 – SAFETY RECORD 1. List your firm’s Workers Compensation Experience Modification Rate (EMR) for the three (3) most recent years. Your EMR should be obtained from your insurance agent. Please attach letter from the insurance agent/carrier identifying the EMR rate for the past three years and also indicating your current EMR rate. 2015 2016 2017 as of 2. Please provide actual information in all boxes – Do not enter the points! Points will be calculated based on entries. 2015 2016 2017 For District Use Only Workers Compensation Experience Modification Rate (EMR) <1= 10 pts, 1.1–1.4 = 5 pts, >1.5 = 0 pts _____ Pts. Number of fatalities 1 or more = 0 pts, 0 = 5 pts _____ Pts. OSHA Violations <0=5 pts, 1-2 = 3 pts, >2 = 0 pts _____ Pts. TOTAL POINTS _____ Pts.
2018%20PreQualification%20Questionnaire%20FINAL%20acc.docx