Loss Prevention Grant Application

Complete the application below to apply for up to $5,000 in reimbursements for expenses that support workplace safety. A committee comprised of three MCWCF trustees will review applications and make funding decisions.

Preference will be given based on the specific need or potential impact to the organization, which is not currently funded through the organization’s budget. Successful applicants must have a workplace safety committee and provide minutes from its last meeting.

Funds are issued as reimbursements after the equipment is purchased. You must file for reimbursement within 90 days of receiving the letter notifying you of your grant award.

Applications must focus on projects that protect employee safety in the workplace. This is a loss prevention program designed specifically to reduce workplace injuries and, consequently, claims on the MCWCF and its members.

If you have any questions about what qualifies as loss prevention and what does not, please contact Eric Waidelich at CompOne at ewaidelich@rizikon.net or (313) 530-8251 BEFORE submitting your application.

Loss Prevention Grant Application
Fields marked with an * are required
Today's Date *

By completing and submitting this form, I give consent for the Michigan Counties Workers’ Compensation Fund to take photographs and give permission for the photos to be published as part of any media notice of the grant program, if I am selected as a grant recipient.

Please include typed responses to the following questions, on a separate sheet, along with this form. Responses should not exceed three (3) pages.

You MUST INCLUDE photos and supporting data with the application.

  1. Briefly describe the proposed project/plan and what purpose would it accomplish.
  2. What is the estimated cost of the project? Please include an itemized list, if appropriate.
  3. Why are outside funds needed?
  4. Who would benefit from this project?
  5. How would you determine the success of the project?
  6. Provide photographs to support your request.
  7. Provide list of active Safety Committee Team members and minutes from last meeting.