2012/04/04 Council Agenda Packet

Attachment B to REQUEST FOR PROPOSALS-Forms , � General Contractor/Construction Manager Services for Water Pollution Control Facility Expansion-Phase C 3. For work in other states (Interstate), please list your Company's Workers' Compensation Experience Modification Rate (Experience Factor)for the most recent three years. State Year Rate Year Rate Year Rate Name 2011. - - 2010 2009 - 2011 2010 - - 2009 --- 2011 2010 2009 2011 2010 2009• . 4. Using the three most recent year's OSHA No. 300 Logs, please fill in the number of cases for each of the following categories: (attach a copy of your last three years of OSHA No. 300 Logs) 2011 2010 2009 A. Number of deaths(Total column G) Please provide a brief description of the circumstances surrounding any employee death(s): B. Number of days away from work and job transfer or restricted workday cases(Total Column H & I) C. Number of other recordable cases (Total Columns J) D. Number of days away from work cases (Total Column H) E. Employee Hours Worked F. OSHA Recordable Incidence Rate (See formula below) G. OSHA Lost Workday Incidence Rate (See formula below) Notes: • Items in parenthesis above come from your OSHA No. 300 Log • Employee Hours Worked = total number of hours worked during the year by all employees • OSHA Recordable Incidence Rate= [(A-+-B+C) x200,000/Employee Hours Worked] • OSHA Lost Workday Incidence Rate= [(D) x 200,000/Employee Hours Worked] 5. Please provide the following safety information for three public construction projects of your Company in which the superintendent proposed for this project was the superintendent. The Incidence Rates reported below must include incidences for the contractor and subcontractors of any tier. City of Everett Page B3 April 16, 2012 Water Pollution Control Facility Expansion-Phase C43