Thomas E. Dwyer
Distinguished Wellness Program Innovation Award
 

Rhode Island Interlocal Risk Management Trust
501 Wampanoag Trail, Suite 501
East Providence, RI 02915
401/438-6511 or Fax 401/434-6094
 
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The Thomas E. Dwyer Distinguished Wellness Innovation Program Award will provide a monetary grant of up to $5,000 which should be used to support a Health Pool Member program that promotes, at a minimum, the benefits of having a well workplace including: reduced healthcare costs, greater workforce productivity, decreased absenteeism, reduced stress levels, improved employee health, and increased morale, to name a few.

For further information regarding The Trust's Safety Enhancement Grant Program contact: Colleen Bodziony, Director of Operations and Member Services Rhode Island Interlocal Risk Management Trust, 501 Wampanoag Trail, Suite 301, East Providence, RI 02915 Tel: (401) 438-6511, ext. 512 / 800 511-5975, Email: cbodziony@ritrust.com

Your Name*
Your Public Entity's Name*
Street Address
City/Town
Your Title*
Email Address*
Telephone
FAX
Please provide a detailed overview of an innovative workplace wellness program or initiative aimed at improving overall employee health
How is this program innovative and outside the scope of your Health Matters wellness program?
How will the program be implemented?
Program coordinator name*
Actual cost or quote of program *


Upload File: Additional Program Description (If Applicable)

Upload File: Cost or Quote Detail (Requested)
 
Terms of Agreement

Terms 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 automatically receive an e-mail receipt from The Trust’s electronic document receiving system for any form submission that requires a valid electronic signature, identifying the document received, the signatory, and the date and time of receipt.

I agree that I will contact the Trust’s Website Administrator if I do not receive an e-mail receipt as specified above within five (5) business days for any submission to The Trust.

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 401-438-6511

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