Training and Risk Management Activity Reimbursement Form

Each participating ERMA member agency is eligible for reimbursement of up to a total of $2,500 per Program Year (7/1 – 6/30), determined by the date of the activity. Expenses should be submitted as soon as possible, but no later than 6/30.

1. Contact Information: *This question is required.

Agency Name

2. Requestor Information: *This question is required.

First Name

Last Name

Email Address

3. Address (for mailing reimbursement) *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State

Zip *This question is required.

4. Type of Loss-Control Activity: *This question is required.

5. Please describe the type of loss-control activity: *This question is required.

6. Name of entity providing training/activity/service: *This question is required.

7. Title of activity: *This question is required.

8. Date of activity: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

9. 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. *This question is required. This question requires a valid number format.

10. Please attach copy of receipt(s).
*If your attachment is too large to load please send an email with your attachment to ERMAtraining@sedgwick.com. *This question is required.

File: {{filename}} delete