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DocuSign Envelope ID:418ADAA3-2F7B-4243-AF32-4541C164B6FA <br /> YEAR CONTRACTOR INDUSTRY INDUSTRY FIELD AND CODE <br /> DART DART <br /> INCIDENT RATE INCIDENT RATE <br /> Z46 11,7 <br /> toiq 0 <br /> zir <br /> 2. Experience Modification Rate (EMR). Provide the bidder's most recent <br /> Experience Modification Rate(EMR) based on insurance claims history. The bidder <br /> must provide the source of the EMR information and contact information of insurer entity <br /> providing the EMR. <br /> YEAR. CONTRACTOR I INDUSTRY FIELD AND NAME AND CONTACT <br /> EMR CODE INFO FOR EMR <br /> INFORMATION <br /> (M (A)mg <br /> sst, 410 <br /> 2Q16 1O6 <br /> (CtftrEge?Pfe-grrvi-J <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 1,7 <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 />