SDML Workers Compensation Fund ICS Saw 2018 Grant Application

Transcription

1 SDML Workers Compensation Fund ICS Saw 2018 Grant Application In partnership with Stan Houston Equipment *To be considered for the SDML WC FUND GRANT, this application must be completed and received or postmarked by 5:00 P.M. December. 31 st 2018 CST.

2 ICS Saw Grant Application Program Information: Background: The SDML Workers Compensation Fund (SDML WC Fund) has funds available to grant to public entities that have their workers compensation coverage through the SDML WC Fund, for the purchase of one ICS Saw Package. Funds will be distributed in a 50/50 matching grant with the SDML WC Fund providing 50% of the SDML Price for the purchase of one of three ICS Saws listed below: 695PG-16 Gas Saw Package 880PG-15 Hydraulic Saw Package 880PG-20 Hydraulic Saw Package In an effort to aid our members who wish to acquire more than the allotted equipment in this grant (i.e. additional ICS Saws and/or additional accessories not listed below) the SDML WC Fund has negotiated a discount available only for SDML WC Fund members. The SDML WC Fund will not provide additional funds for these items. Please reference your affiliation with the SDML WC Fund to Stan Houston Equipment to obtain this negotiated pricing. The ICS Saw Package grant is only for the following saw packages: 695PG-16 Gas Saw Package includes: 695GC Powerhead.(545089)...$1, Chain...(537764)..$ Bar...(524490)..$ Package Regular Price $2, SDML Price $2, PG-15 Hydraulic Saw Package includes: 880F4 Powerhead..(526822)...$3, Chain...(537764)..$ Bar...(523080)..$ Package Regular Price $3, SDML Price $3, PG-20 Hydraulic Saw Package includes: 880F4 Powerhead..(526822)...$3, Chain...(537765)..$ Bar...(529767)..$ Package Regular Price $3, SDML Price $3,

3 Purpose: To provide public entities with beneficial equipment in an effort to reduce risk and injury to the public entity employees during an activity that requires the use of a chop saw. Deadline of Applications: The deadline is 5:00 P.M., Dec. 31 st 2018, CST. Applications must be received or postmarked by this date to be considered for the grant. Applications should be delivered to: SDML WC Fund c/o Insurance Benefits, Inc S. Isabel Pl #110 Sioux Falls, SD info@sdmlwcfund.com Fax It is recommended that the application be sent by or certified mail to receive an acknowledgement of receipt of the application. Applications will also be accepted in electronic form at the address above. Applicants that file applications electronically will receive an confirmation from the SDML WC Fund Administrator. Application Availability: Applications are available online at or can be obtained by contacting Brad Wilson or Ladene Bachtell at Insurance Benefits, Inc. at Award Notification Date: All applicants will be notified of their receipt or non-receipt of awards no later than January 12, Selection Criteria: Applications will be reviewed and funds will be awarded using the following selection criteria: Presentation of a logical needs statement Member s compliance with previous loss control recommendations Member s financial hardship In depth description of the availability of your 50% out-of-pocket funds Grant funds available Agree to only use the ICS Saw to cut pipes in trenches. The saws that are being replaced can be used in some other capacity. Eligibility Requirements: Eligibility: Applicant must be a current member of the SDML Workers Compensation Fund as of the date that the application for the Grant is being made, and in the year the Grant will be distributed. Application Guidelines: The SDML Workers Compensation Fund has the discretion in approving or denying any, all, or a portion of the grant applications. All applications must include the following completed sections: Organization information (page 4) Narrative (page 5) Signature page (page 6) 3

4 Organization Information: Applicant/Member: Address: Department Involved: Project Contact: Phone: Fax: Alternate Contact (if any): Phone: Fax: # Full-time staff: Estimated number of times a chop saw is utilized during the year: Cutting Pipe: Other Uses: Service area size and description: 4

5 Narrative (use additional pages as necessary) Part I. Please circle which item you are applying for: 695PG-16 Gas Saw Package 880PG-15 Hydraulic Saw Package 880PG-20 Hydraulic Saw Package Part II. Needs Statement: a) How many chop saws does your entity/department currently have, please describe (type/brand) of equipment, age and serial number on chop saw. b) Does your entity currently own an ICS Saw? If so, how many? c) Explain how receiving this new ICS Saw will improve employee safety and prevent injuries within your organization. Also, describe your current chop saw user protocol and how you will change it if awarded a grant to purchase an ICS Saw. d) Please include any unique personnel data or information that you would like the SDML WC Fund to know about your entity/department when considering this grant application (i.e. opportunities to use the ICS Saw): Part III. Explanation for lack of available funds: a) Explain why your entity/department needs assistance with funding to purchase this equipment. Please include an overview of the current budget and planned expenditures in FY 2018 and for FY 2019 to provide the matching funds for this grant : b) If benefits of this project will aid or involve other departments, members or organizations, please describe: 5

6 Total budget for the project: Portion funded by applicant: Total from other sources: Additional Information: Signature of applicant: Date: Project and application authorized by: (governing body) Signature (Authorizing Person): Date: Print Name (Authorizing Person): Title: *All ICS Saw Package & accessory equipment pricing quotes may be obtained by contacting: Eddie Haskell (please reference that you are applying for the SDML WC Fund grant)* You may also refer to the Price Sheet on the next page of this application. Eddie Haskell - Sioux Falls Location 501 S. Marion Rd

7 695PG-16 GAS SAW PACKAGE 695GC Powerhead...(545089)...$ Chain...(537764)...$ Bar...(524490)...$ Package Price...$ SDML Price...$ ICS SAW PRICING 880PG-15 HYDRAULIC SAW PACKAGE 880F4 Powerhead...(526822)...$ Chain...(537764)...$ Bar...(523080)...$ Package Price...$ SDML Price...$ PG-20 HYDRAULIC SAW PACKAGE 880F4 Powerhead...(526822)...$ Chain...(537765)...$ Bar...(529767)...$ Package Price...$ SDML Price...$ ICS POWER GRIT ACCESSORIES Power Grit Pipe Clamps...$ Flow Adapter...$ P95 Power Pack...$ Hydraulic Hose Set...$ Gallon Spot Sprayer Model SALE: $ SIOUX FALLS RAPID CITY SIOUX CITY ABERDEEN 501 S. Marion Rd Deadwood Ave. 412 Lewis Blvd th Ave.SW