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<br />4.01 SAFETY & EXPERIENCE RECORD <br /> <br />A. The following statements as to safety and experience of Bidder are submitted. <br />and Bidder guarantees the truthfulness and accuracy of the information: <br /> <br />1. Safety <br /> <br />a. List Bidder's Interstate Experience Modification Rate for the last <br />three years. <br /> <br />2003: 114% <br />2004: 116% <br />2005: 92% <br />2006: 103% <br /> <br />b <br /> <br />Use Bidder's last year's CaVOSHA 200 log to fill in the following: <br /> <br />-0- <br />-0 <br /> <br />Number of lost workday cases <br />Number of medical treatment cases <br />Number of fatalities <br /> <br />-0- <br /> <br />c. <br /> <br />Employee hours worked last year <br /> <br />11 265 <br /> <br />d. State the name of Bidder's safety engineer/manager or Site Safety <br />cnficer: PHIL ROGERS <br /> <br />5.01 CONTRACTOR EXPLANATION OR NOTES ON ANY OF THE ABOVE: <br /> <br />6.01 BIDDER CERTIFIES, UNDER PENALTY OF PERJURY, THAT THE <br />FOREGOING INFORMATION IS CURRENT AND ACCURATE AND <br />AUTHORIZES CITY AND ITS AGENTS AND REPRESENTATIVES TO <br />OBTAIN A CREDIT REPORT AND/OR VERIFY ANY OF THE ABOVE <br />INFORMATION. <br /> <br />Phil Rogers <br />NAME <br /> <br />ROGERS TRUCKS & EQUIPMENT,INC. <br />(COMPANY NAME) <br /> <br />~0----~ pmirlpn~fILE <br /> <br />BIDDER: <br /> <br />BY: <br /> <br />BIDDER CERTIFICATIONS <br /> <br />Page 6 of 7 <br />