Training and Risk Management Reimbursement Request Form

"*" indicates required fields

Agency Name*

Your Name*

First Last

Email*

Address (for mailing reimbursement)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of loss-control activity*

Training

Conference/Meeting

Policy Development

Certification

Other

Please describe the type of loss-control activity:

Name of entity providing training/activity/service*

Title of activity*

Date of activity*

Total reimbursement amount requested*

*Each member is allocated $2,500 for the program. Your reimbursement amount is contingent upon what has already been expended from your Agency,

Please attach copy of receipt.*

Max. file size: 50 MB.

Do you have any additional receipts to attach?

Max. file size: 50 MB.

If you have additional receipts, attach it here. If you have multiple receipts, please send them to [email protected]

Please note, reimbursement requests for the current program year need to be submitted no later than June 30th. If you have questions, please contact [email protected].

Training and Risk Management Activity Reimbursement Request Form