Account Name
Policy Number
First Name
Last Name
Job Title
Phone
Email
Are you currently registered for access to any of Safety National's MAP Client Services online resources? YesNo
Company Description of Operations
Dollar amount of matching grant funds requested, up to $10,000
Detailed information on the loss source that the grant will be used towards
Detailed information on the risk control solution and implementation timeframe
Anticipated benefits of risk control solution with injury cost savings estimate and expected number of employees to be impacted.
I accept the terms and conditions I accept By clicking "I accept" you agree that Safety National has the right to use any information you transmit to this website for any purpose and in any manner deemed appropriate by Safety National. Specifically, you agree to allow Safety National to use your entire grant submission or any portion thereof, including but not limited to the details of your proposed risk control solution(s), for promotional pieces, to disseminate to other Safety National policyholders as a resource, and/or in any other manner determined by Safety National.
Comments