COUNTY GOLD APPLICATION

2023 SAFETY & LOSS CONTROL RECOGNITION AWARD

Completed applications must be received by 08/18/2023

Entity

Date

Contact Person

First Last

Title

Address

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

Phone

GOLD LEVEL

To achieve a Gold Level award, an entity MUST comply with all Bronze and Silver Level items and each of the following Gold Level items. Please answer YES or NO and attach appropriate documentation as requested after certain items.

20. Within the past 36 months, has your entity: • provided a defensive driving course (SBI, MSHA, MMUA, SD Safety Council, etc., or online course) for your employees; AND • devoted at least one safety meeting (tailgate and/or toolbox meetings are acceptable) to a safe driving topic (i.e. distracted driving, use of cell phones, winter driving, etc.)? If yes, for each of the above please attach a roster showing attendees, training/meeting date(s), and specific training topic. For the On-line Defensive Driving Class, please submit a copy of the printed certificate(s) received after successful completion of the course. Comments:

YES

Attach Appropriate Documentation

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.

21. Does your entity provide safety meetings for your employees? If yes, please include training records for the past 12 months indicating meeting frequency and safety training topics covered. Comments:

21. Does your entity provide safety meetings for your employees? If yes, please include training records for the past 12 months indicating meeting frequency and safety training topics covered.

YES

Attach Appropriate Documentation

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.

22. Does your entity conduct documented self-inspections of buildings and properties on a regular basis? Self-inspections consist of a walk through where the person(s) conducting the audit looks for potential hazards. Written recommendations are then given to management for elimination or mitigation of hazards identified. Self-inspections may be of buildings such as shops, playgrounds, sidewalks, parking lots, etc. If yes, please include copies of some audits conducted within the past 12 months. Comments:

YES

Attach Appropriate Documentation

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 GB.

23. Does your entity comply with the Loss Control Checklists (where applicable) provided by SBI for:

To obtain copies of checklists, email Shana Mueller at smueller@safety-benefits.com or call Safety Benefits at (888) 313-0839

Name

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2023 SAFETY & LOSS CONTROL RECOGNITION AWARD

Completed applications must be received by 08/18/2023

GOLD LEVEL

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