Be Careful Out There Workplace Safety Grant Application

Company Name
Policyholder Number
Address:
Applicant name:
Phone:
Email address:
Provide a brief description of your company – (core business)
Name (print) of authorized representative: Position/Title:
Signature of Authorized Representative Date
  1. PROVIDE AN OVERVIEW: How would your company use the grant money for a specific safety project to increase workplace safety at your organization?
  1. DESCRIBE THE PURPOSE OF THIS WORKPLACE SAFETY PROJECT: (Examples: increase workplace safety, reduce accidents, increase employee awareness, establish a new safety program, augment a current safety initiative, etc.)
  1. DETAILED PROJECT DESCRIPTION: Provide a clear and concise description of how the project will be implemented and relevant information that will assist us in evaluating your proposal.
  1. SAFETY EXPERTISE: Identify all key individuals by name and title, directly involved in implementation of this project. Specify if they are current employees or will hire subcontractors. Provide their safety credentials, certifications, and background in implementing safety initiatives.
  1. TARGET AUDIENCE AND OVERALL IMPACT: Describe your target audience and provide an estimate of how many people will benefit DIRECTLY as participants in this project. (Attendees at workshops, conferences, number of employees trained, etc.).
  1. PROJECT EVALUATION & SUCCESS METRICS: Describe how the effectiveness of your initiative and successful program implementation will be measured. Include project metrics for PRE & POST EVALUATION to measure successful outcomes.
  1. PARTNERSHIPS:Provide information about any partnerships that will help leverage resources, encourage participation, or strengthen your ability to carry out this project.
  1. DETAILED BUDGET: Provide a specific costs breakdown and explain how funding will be allocated. Including explanation of any matching funds.

Grant Requirements:

  1. Applicants must be a current policyholder of WCF Insurance.
  2. A fully-completed application must be submitted by 8 a.m. by June 1, 2017.Applications may be submitted either by mail or electronically:

By mail:WCF Insurance

Workplace Safety Grant ProgramC/O Rachel Jepperson

100 West Town Ridge Parkway

Sandy, UT 84070

E-mail:

  1. Implementation of the agreed upon purchases must be completed within one calendar year from the date on which the grant recipient is notified of grant approval.
  2. Successful grantees may be audited by WCF Safety and Health to ensure implementation of the agreed upon expenditures.
  3. Successful grantees will work closely and cooperatively with the WCF Safety and Health team to ensure the best-desired outcome.