Employers Mutual Limited is an Australian owned mutual and a partner with ASWIG management in the EML Group. Employers Mutual Limited, via the Mutual Benefits Program, reinvests funds back into services, projects, and research initiatives to assist employers to create safer workplaces and support workers get their lives back and return to work following injury.

This form is to be completed by an EML Group client, to request funding to support a project within their workplace.

FUNDING APPLICANT
REGISTERED BUSINESS NAME
EML GROUP CUSTOMER OR MEMBER (if this varies from the above)
POLICY NUMBER
KEY CONTACT	Name: Title: Phone: Email:
BROKERAGE OR INTERMEDIARY (if applicable)
PROVIDER NAME/S *

* Exclusive discounts are available for EML Group customers with these EML Offer providers.

INITIATIVE DETAILS
Initiative Name
Short Description (high level overview of the purpose of the initiative, including an outline of the problem to be solved) Max 100 words
Key Deliverables (What will this project produce? The measurable outcomes the initiative will achieve, e.g. delivery of training course to 50 managers, development of 4 new job descriptions)

FUNDING REQUEST
COST	FY25 Mutual Benefits funding requested (excl. GST)	$
Customer contributions (excl. GST)	$
Total cost of initiative (excl. GST)	$
INVOICE SCHEDULE	☐ Once only e.g., at project completion	☐ Quarterly	☐ Bi-annually	☐ Annually
☐ Other provide details:

EXPECTED BENEFITS
Request a copy of our Benefits Framework if assistance is needed to complete this section. Expected benefits should define the longer term, broader benefits that should be achieved as a result of the initiative delivering the objectives. The benefit must note a baseline measure, a target, and the timeframe for achieving the target. Benefit Indicator Define the Benefit Baseline Measure Target Measure & Timeframe Example: Reduce frequency of injuries Claims volumes Reduce the total volume of psychological claims lodged 2.5 claims lodged / month (30 claims lodged / year) 3 months after initiative: 1.7 claims lodged / month 12 months after initiative: 1.25 claims lodged / month (15 claims lodged / year) Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item.

SCHEDULE
Include up to 4 key milestones for the delivery of the initiative. Key Milestone Date Initiative Start Initiative Complete
How frequently will status reports be provided to EML Group?	☐ Monthly	☐ Quarterly	☐ On Project Completion Only

ADDITIONAL COMMENTS TO SUPPORT APPLICATION:

AUTHORISATION
Requestor / Author	Name: Title: Email:
On behalf of Applicant organisation (employer business or company name)
Acceptance of terms and conditions	☐ I confirm that I am authorised to apply for Mutual Benefits funding on behalf of the Applicant and that the information provided is true and correct to the best of my knowledge. ☐ I understand that invoices issued to EML Group for Mutual Benefits funding must be issued in the name of the Funding Applicant. ☐ I understand that invoices will not be paid unless accompanied by a Project Completion Report, or other evidence of the services having been delivered. ☐ I have read, understood and agree to the Terms and Conditions.
Signature
Date

Attach all supporting documents, including:

Proposal or quote from provider

A supplier form is to be completed by the Funding Applicant. (Note: this is not required if the applicant has previously been setup, and no changes have occurred).

Note: A formal agreement and / or letter will be issued if the application is approved following internal evaluation.

INTERNAL EML GROUP AND MUTUAL BENEFITS USE ONLY
INITIATIVE DETAILS
EML Group Account Manager	EML Group Business Owner (GM level sponsor)
Funding offered via:	☐ RMF	☐ Tender / Contract	☐ Other (please specify):
Strategic Alignment	SELECT ONE ONLY ☐ Injury Management: Uplift performance above reasonably achievable operational targets. ☐ Research & Innovation: Be recognized as a leader in WHS & injury management. ☐ Customer Value: Deliver value to customers over and above what they would receive from another insurer. ☐ Business Sustainability: Support new and diverse growth opportunities. ☐ Injury Prevention: Invest in programs to prevent workplace injuries.
Funding Pool (For a description of each pool and their relevant owner, click here)	☐ Central Strategic	☐ Central Innovation	☐ FSI	☐ HII
☐ IfNSW	☐ Insurance Industry Engagements	☐ NI	☐ NSI
☐ Products & Tools	☐ SA	☐ Trinity	☐ VIC
☐ Other:
Industry Alignment (the industry that will primarily benefit from the initiative. Select only one)	☐ Construction	☐ Transport	☐ Health & Aged Care
☐ Emergency Services	☐ Retail	☐ Hospitality
☐ Education	☐ Other: (please specify):
Initiative Type (select only one)	☐ Client Tools / Frameworks / Systems	☐ Training	☐ Project	☐ Other:
Funding Category (select only one)	☐ Mutual Services: to fund services for the direct benefit of EML Group customers. ☐ Mutual Capability: to improve EML Group’s internal capability in the provision of services to its customers. ☐ Commercial: agreements with third party providers to further EML Group’s strategic objectives.
Focus Topic (if applicable, select only one)	☐ Recovery & RTW	☐ Physical & Psychosocial WHS	☐ Mental Health
☐ Musculoskeletal	☐ Capability & Confidence	☐ Technology & Tools
☐ Other (please specify):
EML Offer Utilised	☐ Yes	☐ No

APPROVALS
Name & Signature	Date
EML Group Account Manager
General Manager, Mutual Benefits
EML Group Business Owner
Other internal approvals