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f <br /> Dec 1713 01:54p L A Downey&Son Inc. <br /> 919-688-4857 p•4 <br /> .1 <br /> YEAR CONTRACTOR INDUSTRY INDUSTRY FIELD AND CODE <br /> DART DART <br /> INCIDENT RATE INCIDENT RATE <br /> 2. Experience Modification Rate MR). Provide the bidder's most recent <br /> Experience Modification Rate(EMR)based on insurance claims history. The bidder <br /> inust provide the source of the EMR information and contaci information of insurer entity <br /> providing the EMR. <br /> YEAR CONTRACTOR INDUSTRY FIELD AND NAME AND CONTACT I <br /> EMR CODE INFO FOR EMR <br /> INFORMATION <br /> 3 Answer the following OSHA Specific Questions: <br /> (a) Within the last 2 years,has the bidder received any citations classified by <br /> OSHA.as being(1)serious,(2)willful and/or(3)repeat violations where your <br /> company operates? <br /> Yes No <br /> If yes, attach a copy of each such citation and violation. <br /> (b) Has the bidder experienced any work-related fatalities within the last five <br /> years? <br /> Yes No <br /> F- <br /> f <br /> F <br /> i <br /> t <br /> i <br /> t <br /> i <br />