Safety Enhancement Grant • 2022-2023 Application The Trust’s Annual Safety Enhancement Grant Program provides an opportunity for Trust Members to apply for grant funding to support the purchase of safety equipment and/or services that help to promote a positive safety culture, a safer working environment, and reduce the frequency and severity of claims. Members in the Workers’ Compensation and/or the Property/Liability Programs are eligible to apply, and submissions must coincide with your respective Program. Each year, The Trust offers $30,000 in Grants to Members. At least thirty grants are awarded each year, in an amount of up to $1,000.Name* Title* Member* Department* Address* Street Address City State / Province / Region ZIP / Postal Code PhoneEmail* Please select which Program(s) apply* Workers' Compensation Property/Liability Please provide a description of the safety equipment/service you are considering to purchase*Why is this safety equipment/service needed? Please explain how this safety equipment/service will help to promote a positive safety culture, a safer working environment, and/or reduce the frequency and severity of claims*What is the cost of the safety equipment/service? Please attach documentation of a quote or actual cost.*SUPPORTING DOCUMENTATIONQuote or Actual Cost of the Safety Equipment/Service*Max. file size: 50 MB.Additional information regarding your applicationMax. file size: 50 MB.Terms of AgreementTERMS AND CONDITIONS FOR ONLINE FORMS SUBMITTAL ELECTRONIC SIGNATURE AGREEMENT By clicking on the "submit" button, you agree to these Terms and Conditions for online forms submittal with Rhode Island Interlocal Risk Management Trust (“The Trust”) and understand and/or agree to the following: I understand that this Electronic Signature Agreement allows me to submit electronic documents to The Trust’s electronic document receiving system for authorized claims and other information in lieu of paper submissions. I understand that The Trust has developed this Agreement, and allows for the submission of forms online, in accordance with the Uniform Electronic Transactions Act which is codified at R.I. Gen. Laws §42-127.1-1 et seq. I agree that I will review the contents of all electronic submissions prior to submission. I understand and agree that I will be legally bound, obligated, or responsible by my use of my electronic signature as I would be using my hand-written signature. I understand that I will have the opportunity to review the document submitted in a human-readable format and an opportunity to repudiate the electronic document based on this review. I understand that The Trust will automatically reject any electronic document submitted without a valid electronic signature if such signature is required. I understand that The Trust may contact the Member Official for the Member who has authorized me as signatory for the Member in order to verify my identity . I agree to notify the Trust’s Website Administrator if I cease to represent the Member as signatory as soon as this change in relationship occurs. I agree to retain a copy of this signed agreement as long as I continue to represent the Member as signatory of the Member’s electronic submissions. THE TRUST SHALL BEAR NO LIABILITY OR RESPONSIBILITY FOR ANY LOSSES OF ANY KIND THAT YOU MAY INCUR AS A RESULT OF AN ERRONEOUS STATEMENT, ANY DELAY IN THE ACTUAL DATE ON WHICH YOUR FORM IS SUBMITTED, OR FOR YOUR FAILURE TO PROVIDE ACCURATE AND/OR VALID INFORMATION AS REQUIRED ON THE FORM. The Trust reserves the right to change these terms and conditions at any time. Notice of any such change may be given on or with your bill or by other methods. FOR MORE INFORMATION Call 401-438-6511Consent* I have read and accept the above Terms of Agreement