GRIP on Safety Excellence Award 123 Please use the form below to apply for the GRIP on Safety Excellence Award. If you prefer, you can download and mail in the form HERE. You will receive a confirmation email once you complete this form.Name(Required) First Last Email(Required) PhoneSection 1 - Company InformationEnter your company name, address, contact information, CEO/Owner Name, business category, number of employees and total hours reported annually to Labor and Industries. If applying for the GRIP On Safety Excellence GOLD Award be sure to click 'Yes' in the section below.Company Name(Required)L&I Account NumberAddress Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code ContactsPresident / CEOName First Last PhoneEmail Safety ContactName First Last PhoneEmail EligibilityCheck all that apply and attach supporting documentation where noted.Current GRIP member in good standing? Yes No No in-patient hospitalizations, amputations, loss of eye, or fatalities in the past (3) three years or in application year and no time loss claims in the current year. Yes No No willful, repeat or failure-to-abate DOSH safety violations in the past (3) three years or in application year. Yes No Attach screenshot of most recent experience modification rating (EMR) below 1.0.You can go to https://secure.lni.wa.gov/verify/ and use the SEACH BY… to find your public company profile, which will include EMR and citation history.Max. file size: 512 MB.Attach most recent OSHA 300A Summary Report form to application.https://www.osha.gov/sites/default/files/OSHA-RK-Forms-Package.pdfMax. file size: 512 MB.Claim frequency rate from most recent OSHA 300A Summary Report that is below the WA State NAICS industry average. (https://data.bls.gov/iirc/) Yes No CertificationI certify that the information provided is accurate and that our company meets the eligibility criteria for the GRIP on Safety Excellence Award.SignaturePhoneThis field is for validation purposes and should be left unchanged. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
