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DocuSign Envelope ID: B94F2D40-3B3C-47A7-86C2-6F1B4F92C62C <br /> YEAR CONTRACTOR INDUSTRY INDUSTRY FIELD AND CODE <br /> DART DART <br /> INCIDENT RATE INCIDENT RATE <br /> O C� . jc. LjZ z <br /> . O i �z h��a <br /> 1� d. 0 l S4' Z- a 3 &Lz o <br /> 2. Experience Modification Rate (EMR). Provide the bidder's most recent <br /> Experience Modification Rate (EMR) based on insurance claims history. The bidden <br /> must provide the source of the EAR information and contact information of insurer entity <br /> providing the EMR. <br /> YEAR CONTRACTOR INDUSTRY FIELD AND NAME AND CONTACT <br /> EMR CODE INFO FOR EMR <br /> INFORMATION <br /> as � 1/"Z- <br /> Z ZvS.3 fa-ZZ-S--0 5'q 1 <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 />