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2024 SAFETY & LOSS CONTROL RECOGNITION AWARD

City Silver Application

Completed applications must be received by 09/13/2024

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SILVER LEVEL

To achieve a Silver Level award, an entity must comply with all Bronze Level items and each of the following Silver Level items. Please answer YES or NO and attach the appropriate documentation as requested.
11. Has your entity developed a formal Safety Committee and/or appointed a Safety Coordinator? If yes, please attach information on your committee and/or safety coordinator. Please include date formed/appointed, number of members, duties, and date of last meeting, etc. Please include copies of minutes from Safety Committee meetings for the past 12 months.
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
12. Does your entity obtain Certificates of Insurance, additional insured endorsements and hold harmless agreements from contractors? (Liability and Worker’s Comp) If yes, please attach some samples.
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
13. Has your entity adopted a formal accident/incident investigation and evaluation program? If yes, please include any written policies or submit an explanation of how the program works. If a copy was submitted last year, a new one only need be submitted if the policy/program was revised. Please note if information was submitted previously. Revision Date: __________
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
14. Does your entity document complaints of potential liability issues from citizens? (i.e.: signs down, bad roads, bad sidewalks, obstructed view intersections) If yes, please include a sample of the form used. If a copy was submitted last year, a new one only need be submitted if the program was revised. Please note if information was submitted previously. Revision Date: ______________
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
15. If your entity has a law enforcement agency covered by the SDPAA: Has the agency adopted policies and procedures in the 12 critical tasks as recommended by the SDPAA? AND Is annual training on these policies and procedures provided to officers/deputies? If yes to each, please attach a copy of the Table of Contents page.
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
16. Has your entity provided back injury prevention/safe lift training for employees in the past 12 months (online training is acceptable)? If yes, please attach a roster with attendee names, training date(s) and training topic.
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
17. Has your entity provided slip, trip and fall prevention training in the past 12 months (online training is acceptable)? If yes, please attach a roster with attendee names, training date(s) and training topic.
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
18. Did a representative(s) of your entity attend the 2022 Joint Safety and Loss Control Training Conference in November in Pierre? If yes, please note who attended.
19. Does your entity have a personal protective equipment (PPE) program for employees? If yes, please attach information outlining your program. If information was submitted last year, new information only need be submitted if the program was revised. Please note on application if information was submitted previously. Revision Date: ______________
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.
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Safety Benefits, Inc. South Dakota

Safety Benefits Inc.
602 E. State Street
Plankinton SD 57368

605.334.9567
888.313.0839

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