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DocuSign Envelope ID:46276B05-79E0-4089-B879-E62E97F0B2A1 <br /> YEAR CONTRACTOR INDUSTRY INDUSTRY FIELD AND CODE <br /> DART DART <br /> INCIDENT RATE INCIDENT RATE <br /> / 7.* <br /> 0 <br /> 2. Excellence Modification Rate(EMR). Provide the bidder's most recent <br /> Experience Modification Rate(EMR)based on insurance claims histoty. The bidder <br /> must provide the source of the EMR information and contact information ofinsurer entity <br /> providing the EMR. <br /> YEAR <br /> CONTRACTOR INDUSTRY FIELD AND NAME AND CONTACT <br /> EMR CODE INFO FOR EMR <br /> INFORMATION <br /> Sq-0 Tou.A- 4.41— <br /> Ck\CA SL1/41/4 <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(I)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 />