HAZARD ELIMINATION LEARNING PROGRAM APPLICATION ADDENDUM EMPLOYER SERVICES DIVISION SFN 54499 (11/2005) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE NUMBER (701) 328-3800 TOLL FREE FAX NUMBER 1-888-786-8695 TDD NUMBER (for the hearing impaired only) (701) 328-3786 www.WorkforceSafety.com The purpose of this application is for successful HELP applicants to submit a variance in costs when: the costs no longer match the proposed initial estimate on the original HELP application, or the costs have changed with the vendor since the time application was made, or additional equipment is needed, or an adjustment needs to be made with the safety intervention. As in accordance with the HELP agreement, any reimbursement request amount that does not coincide with the grant application will not be reimbursed without an addendum approval from WSI. The revised vendor’s estimate of costs must be submitted with this addendum application. SECTION 1 – EMPLOYER INFORMATION Name of Employer Employer Contact Name Employer Address Title City State Zip Phone Number Email Address WSI Employer Account Number Applicant Signature Fax Number Date SECTION 2 – REVISED BUDGET Please provide the revised budget for the project. Please complete the itemized expense information for your project. Attach additional sheets if necessary. Please be sure to mail the original vendor price quotes for the proposed items. Item Quantity Cost/Unit Total Grand Total SECTION 3 – PROJECT COST Due to the change in the safety intervention costs, the amount supplied by the applicant may increase, as well as the amount supplied by WSI, but the WSI amount cannot exceed the lifetime maximum amount. Please use the revised budget to complete the project costs table below. Standard premium (manual premium as modified by the experience rate surcharge or discount) for the most recent completed premium year: Total Amount of project (A) (A/6 = B) Total Amount supplied by applicant Total Amount supplied by WSI (WSI total not to exceed lifetime maximum as shown above) (B) (A-B) American LegalNet, Inc. www.USCourtForms.com