EMS GOLD APPLICATION - Safety Benefits, Inc.

2025 EMS Gold Application

2025 EMS Safety & Loss Control Recognition Awards Application

Service:(Required)

Date:(Required)

Contact Person:(Required)

First Last

Title:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:(Required)

Email Address:(Required)

Member of (please select one):(Required)

DUE DATE: 01/22/2025

GOLD LEVEL

To achieve a Gold Level award, your service must comply with all Bronze Level, Silver Level AND Gold Level items. Be sure to submit Bronze, Silver and Gold Level applications. Please answer yes or no to the questions below and attach the appropriate information/documentation where requested.

17. Has your service provided drivers with Emergency Vehicle Operator training within the past 2 years? If yes, please provide the information noted below:

* Attach a training roster noting the training date(s), trainer, attendees, and the kind of training (safety committee meeting, video, in person, etc.) * For the On-line Defensive Driving Class, please submit a copy of the printed certificate received after successful completion of the course.

Untitled(Required)

Yes

Attach Documents

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB, Max. files: 15.

18. Does your service conduct written/documented self-inspections of your buildings and properties on a regular basis (i.e. monthly or quarterly)?

* Explanation: Such self-inspections consist of a walk through conducted specifically to identify hazards. Hazards identified are documented and written recommendations are provided to management for correction. Examples of such audits might include self-inspections of buildings such as shops, sidewalks, parking lots, etc. * If yes, please include some samples of self-inspections conducted within the past 12 months.

Untitled(Required)

Yes

Attach Documents

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB, Max. files: 15.

19. Does your service comply with the Emergency Medical Services Loss Control Checklist (where applicable) provided by SBI?

Please see the attached form.

Untitled(Required)

Yes

Attach Emergency Medical Services Checklist

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB, Max. files: 15.