Partners in Safety Grant Program Application

Instructions: When completing this form, make sure to gather the documents that support the statements below. Your organization is required to maintain these documents and provide them to GMA for audit upon request

Please complete all required fields. All communication will be conducted via email.

On behalf of my organization, I affirm that the following statements are true and correct to the best of my knowledge.

Eligibility and Program Participation

Please find your Participating Employer from the drop-down below. If your Participating Employer is not listed, your organization is not eligible for the Partners in Safety Grant at this time. If you have questions regarding this, please contact riskcontrol@gacities.com.

Participating Employer*

I am authorized by the Participating Employer (the Employer) named above to affirm the accuracy of these statements.

The Employer is current with all required contributions and fees, with no past-due amounts owed.*

Contact your finance department to ensure this statement is accurate.

In the past 12 months, at least one employee of the Employer has attended a GMA Risk Control training course or Crisis Coordinator training.*

If you don't have a certificate of completion on file, contact riskcontrol@gacities.com to ensure this statement is accurate.

The Employer has not failed to respond to any written recommendations from GMA Risk Control consultants.*

The Employer has designated a Safety Coordinator or Law Enforcement Risk Specialist, and the required training for that designation has been completed.*

Required Policies and Implementation

The Employer has adopted and implemented a written policy requiring safety meetings on no less than a quarterly basis.*

(NOTE TO APPLICANT: A copy of the safety meeting policy and proof of safety meetings, such as agendas and/or other meeting materials, is required for audit purposes.)

The Employer has adopted and implemented a written policy requiring safety self-inspections, with a minimum of two inspections per year.*

(NOTE TO APPLICANT: A copy of the self-inspection policy, along with documentation of completed inspections, is required for audit purposes.)

The Employer has adopted, distributed, and implemented a written policy requiring seat belt usage.*

(NOTE TO APPLICANT: A copy of the seat belt policy is required for audit purposes.)

Date of Application*

Key Grant Contact (All grant communications will be sent to this employee)

First Name*

Last Name*

Title

Email Address*

Mayor or Top Administrator's Information (Authorized to sign grant agreement on behalf of the organization)

First Name*

Last Name*

Title

Email Address*

Supporting Documents

Upload documents that you would like to include with your application. Members with premiums over $100,000 are required to upload the completed Safety Action Plan.

Upload supporting documents (PDF, DOC, XLSX, images)

Maximum 10MB per file

Items Requested

Please select a Participating Employer above to see available items.

Other

Total Requested Amount:$0.00

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Partners in Safety Grant Program Application

Please complete all required fields. All communication will be conducted via email.

On behalf of my organization, I affirm that the following statements are true and correct to the best of my knowledge.

Eligibility and Program Participation

Participating Employer*

I am authorized by the Participating Employer (the Employer) named above to affirm the accuracy of these statements.

The Employer is current with all required contributions and fees, with no past-due amounts owed.*

Contact your finance department to ensure this statement is accurate.

In the past 12 months, at least one employee of the Employer has attended a GMA Risk Control training course or Crisis Coordinator training.*

If you don't have a certificate of completion on file, contact riskcontrol@gacities.com to ensure this statement is accurate.

The Employer has not failed to respond to any written recommendations from GMA Risk Control consultants.*

The Employer has designated a Safety Coordinator or Law Enforcement Risk Specialist, and the required training for that designation has been completed.*

Required Policies and Implementation

The Employer has adopted and implemented a written policy requiring safety meetings on no less than a quarterly basis.*

(NOTE TO APPLICANT: A copy of the safety meeting policy and proof of safety meetings, such as agendas and/or other meeting materials, is required for audit purposes.)

The Employer has adopted and implemented a written policy requiring safety self-inspections, with a minimum of two inspections per year.*

(NOTE TO APPLICANT: A copy of the self-inspection policy, along with documentation of completed inspections, is required for audit purposes.)

The Employer has adopted, distributed, and implemented a written policy requiring seat belt usage.*

(NOTE TO APPLICANT: A copy of the seat belt policy is required for audit purposes.)

Date of Application*

Key Grant Contact (All grant communications will be sent to this employee)

First Name*

Last Name*

Title

Email Address*

Mayor or Top Administrator's Information (Authorized to sign grant agreement on behalf of the organization)

First Name*

Last Name*

Title

Email Address*

Supporting Documents

Upload documents that you would like to include with your application. Members with premiums over $100,000 are required to upload the completed Safety Action Plan.

Upload supporting documents (PDF, DOC, XLSX, images)

Maximum 10MB per file

Items Requested

Please select a Participating Employer above to see available items.

Other

Total Requested Amount:$0.00