SAMPLE. Eligibility requirements and instructions: Eligibility:

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1 Eligibility requirements and instructions: Eligibility: To be eligible for a safety grant, policyholders must: *Have an active MEM policy from the application date through the awarded date. *Be current on all balances owed to MEM throughout the application timeframe. *Demonstrate the need for specific safety intervention through a properly completed application. *Not have received a safety grant within the current calendar year. *Not have met the 24-month safety grant dollar limit of $20,000. Safety grant funds may be used to purchase ergonomic, safety and/or industrial hygiene equipment. For every $1 you invest, MEM will match it up to $20,000. Safety grants will be awarded for up to five items with a minimum service-life of five years. The minimum amount awarded will be $1,000 before the MEM match. If the requested amount is greater than $10,000, or your annual premium, MEM must perform a Loss Prevention consultation prior to the submission. Safety grants may not be used for: *Any prior purchases, including equipment already ordered, paid for or received. *Rented or leased equipment. *Expense of testing or trying out equipment. *Professional consultants or training. *Salaries, wages, internal labor or the cost of preparing the application. *Costs associated with installation of approved equipment. Please ensure that all information provided on your safety grant application illustrates the significance of the problem and the effectiveness of the proposed intervention. Incomplete applications will be returned for additional information. Please limit the use of any identifying information on your application. You will be required to complete an Eligibility Check and an Application. The eligibility check will confirm that you meet the requirements to apply. Eligible policyholders will be provided with the option to complete an application. If you have questions, contact our Safety Grant Coordinator at safetygrants@mem-ins.com. Policy number Please provide your insured number, your insured number is the center section of your policy number (e.g., if your policy number is MEM , provide ). POLICYHOLDER INFORMATION Name of insured Doing business as (DBA) Address Address Line 1: Address Line 2: City: State: Zip Code:

2 Tax identifier on policy Provide the tax identification number associated with the policy without dashes (e.g., SSN, FEIN). Policyholder contact Please identify an individual who can serve as the MEM point of contact for the safety grant application and future reporting. Policyholder contact: Title: Telephone number (xxx-xxx-xxxx): address: Secondary Policyholder contact Secondary Policyholder contact person: Title: Telephone number (xxx-xxx-xxxx): address: Name: Title: Provide a listing of individuals with a role in the implementation of the proposed intervention Name Job Title Roles and responsibilities on implantation Provide the name, title, phone number and of the individual responsible for the data reporting and case study of successful applications. Use the policyholder contact listed on the previous page Contact information Phone Number: Contact information Name: Title: Phone Number:

3 ATTESTATION I hereby affirm and attest that all information provided in this application is true and accurate. I understand that if selected for an award, all funds are to be used exclusively toward the reimbursement for implementation of the approved intervention included in this application, and that my organization s qualification for any future grant awards is conditioned upon our providing MEM with relevant data related to the risk reduction outcome of the intervention funded by this grant. I understand that information must be provided regardless of any subsequent change in insurer to maintain eligibility for future awards. Printed name Date / / (YYYY/MM/DD)

4 BASELINE OPERATION In order for MEM to evaluate the effectiveness of our safety grant program, it s important we gather the correct data. Please provide accurate information. 1. Baseline reporting period Baseline data is the number of employees, effective hours and claims associated with the operation of concern in the past 24 months. The period start and end dates should span 24 months and the end date should be no more than one month from the date the application was submitted (e.g., if Company X intends to submit their grant application on January 3, 2016, the period end date for the baseline reporting period will be no earlier than December 3, The period start date for the baseline reporting period will be December 3, 2013). Period start date / / (YYYY/MM/DD) Period end date / / (YYYY/MM/DD) 2. Number of full-time employees in area of concern Provide the number of full-time employees that will be directly affected by the proposed intervention. A full-time employee can be counted for every 40 hours worked in the operation of concern in a typical week (e.g., Company X has a total of 6 employees who work half of their work week ~20 hours each in the operation of concern, this is three full time employees). 3. Number of claims, or injuries, experienced during the reporting period Identify the number of, and list the claims/injuries that are related to the operation of concern that would be affected by the proposed intervention Listing of claims Please enter only up to the first thirty claims. Do not list claims that are outside the operation of concern or outside the 24 month window. Please use the claim number provided by MEM or your prior carrier. If you do not have a listing of claims, you can get them from your agent for your prior carrier. For MEM claims, please use our website, to view a full claim list. For questions on how to access your MEM claim history, please contact our Customer Service Department at Claim Number Carrier Name Date of Injury Date Reported Injury Cause Total Incurred 1 OPERATION OF CONCERN 1. Provide a brief description of your organization, as well as an overview of current work/projects.

5 Select your industry, and the operation of concern your organization best fits. You may only choose one. Construction Healthcare - Social Assistance Administrative - Support - Waste Mgmt - Remediation Svc Educational Services Wholesale Trade Real Estate - Rental - Leasing Agriculture, Forestry, Fishing - Hunting Professional, Scientific - Technical Services Other Services Finance - Insurance Transportation - Warehousing Retail Trade Manufacturing Public Administration Arts, Entertainment - Recreation Mining Accommodation - Food Services Utilities Information Other 2. Describe the job/tasks and the operation of concern within the organization where the intervention would be implemented (include videos/photos where possible). How many photos/videos would you like to upload to your application? 1-10 Please describe photo or video #1 - # Describe the current situation/condition as it relates to the job tasks and responsibilities in the operation of concern. 4. Indicate the primary type of exposure, or risk factor associated with the job/tasks in the operation of concern. Strain or injury by Fall, slip, or trip injury Struck or injured by Cut, puncture, scrape, injured by Motor vehicle Striking against or stepping on Caught in, under, or between Burn or scald - heat or cold exposures - contact with Rubbed or abraded by 5. Describe the frequency of injuries/illnesses that occurred in the operation of concern over the past 24 months.

6 6. Describe the frequency of near misses that occurred in the operation of concern over the past 24 months. 7. Describe the nature and severity of the injuries/illnesses that occurred in the operation of concern over the past 24 months, highlighting any that involved lost time from work. 8. Indicate the body parts affected by these injuries/illnesses. Check all that apply. Lower back Upper back Shoulders Knees Hands Feet Elbows Legs Neck Eyes System wide Other, if other please specify 9. Provide estimates or costs for the monetary impact of injuries/illnesses beyond the cost of work comp claims, such as hiring of replacement staff, overtime costs, purchase of equipment, etc. 10. Provide an estimate of employee turnover rates within the operation of concern. PROPOSED INTERVENTION/CONTROL 1. Provide a list of equipment to be purchased.

7 2. Provide detailed information about how the equipment will work as an intervention (e.g., links to websites, brochures, photographs, testimony, etc). 3. Describe how the intervention will eliminate or significantly reduce injury/illnesses or exposure to risks/ hazards compared to the current conditions. 4. Describe how employees will be trained to use equipment. 5. Does the proposed intervention create additional risk/hazard? If so, describe these risks/hazards and how they will be mitigated. 6. Will the intervention cause productivity to increase, decrease, or stay the same? Provide estimates for how much it will change (e.g., increase of productivity of one more work unit per hour). 7. Will the intervention cause quality to increase, decrease, or stay the same? Provide estimates for how much it will change (e.g., reduce defect count by 10 per 1,000 units). 8. Provide a description of the estimated cost-effectiveness of the proposed intervention. A cost benefit analysis or Return on Investment (ROI) could be included: ROI can be calculated by summing dollar gains and costs,then dividing by costs (e.g., if one injury where the average injury costs $1,000 in claims for an investment of $100 is eliminated, the ROI is / 100 = 9, 9 * 100 = 900%). IMPLEMENTATION/BUDGET 1. Provide a description of the plan to implement the proposed intervention. Approved applicants have 120 days from award date to implement and request reimbursement.

8 2. Provide an itemized list and cost for the proposed intervention. Indicate exact costs, do not use estimates. A maximum of five items can be listed. If you need more than one of the same item, you will need to list in multiple times. Item 1 Item 2 Item 3 Item 4 Item 5 3. Do you have ownership, partnership or any other affiliation with the vendor of the equipment being purchased? No Yes, please explain 4. Totals: Applicants should not purchase equipment prior to notice of approval as this may result in denied reimbursement. The safety grant award cannot be used for equipment that has already been purchased. Total budget (must be a minimum of $2,000) Award request to nearest whole dollar (total budget / 2 or $20,000 whichever is least): Is your award request above $10,000? Yes No

9 MEASUREMENT AND REPORTING Learning more about your safety initiatives will help MEM increase and target funding for future safety grants. MEM requires grant recipients to provide eight reports over a two-year period on the area of operation. The first reporting period begins once the 120 day window for implementation has closed. You will receive a reminder ten days prior to the opening of the first reporting period. After one year, MEM requires a case study on how the intervention improved your business. You will also receive a reminder ten days prior to this period opening. The case study should include: overall company description of operations; description of operations before and after the intervention with pictures and/or video; impact to productivity or turnover rates, quality of operations, employee morale or work-related injuries. 1. Describe how this intervention will advance the goal of MEM to provide information to employers, in Missouri, on how to have safer workplaces. List how the information gained from your proposed intervention and the resulting case study you submit could benefit other employers in the state. Ready to submit? Select Save and Exit to submit your application Thank you for your application. If the requested amount is greater than $10,000, or your annual premium, a Loss Prevention consultation will be scheduled to assess the facility and area of operation prior to the review of the application. This assessment provides the MEM Safety Grant Review Committee with an impartial view of overall safety practices and an evaluation of any proposed interventions. If we are unable to conduct the consultation prior to the closing of the application window, your application will remain in our system. This will give you the ability to reapply during our next grant cycle. If you have any questions, please contact our Safety Grant Coordinator at safetygrants@mem-ins.com.