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Get FL DBPR FLRT 3111 2010-2024

The policy period is from to. Must be a specific date MM/DD/YY Employer Signature Title of Signer TO BE COMPLETED BY THE INSURANCE CARRIER OR CARRIER S DULY AUTHORIZED AGENT I HEREBY CERTIFY THE ABOVE STATEMENT IS CORRECT AND THAT THE POLICY COVERS THE TRANSPORTATION OF WORKERS. Name of Insurance Agency Signature of Insurance Representative Street Address or Post Office Box Date FLRT Form 3111 Rev. 7. Division of Regulation Jerry Wilson Director 1940 North Monroe Street Tallahassee FL 32399-2212 Phone 850. 488-6603 Fax 850. 487-9622 Ken Lawson Secretary Rick Scott Governor FLORIDA FARM LABOR REGISTRATION AND TESTING WORKERS COMPENSATION INFORMATION Workers Compensation Coverage Provided by Contractor s Employer Name of Contractor/Corporation Social Security or License Number Street Rural Route or Post Office Box City State and Zip Code Effective this date I NAME ADDRESS AND PHONE NUMBER OF EMPLOYER will pay the premium for Workers Compensation Insurance on you and your crew members as long as you are in our employment. I understand that this coverage will also be used to cover the transportation of workers. Our policy number is. Division of Regulation Jerry Wilson Director 1940 North Monroe Street Tallahassee FL 32399-2212 Phone 850. 488-6603 Fax 850. 487-9622 Ken Lawson Secretary Rick Scott Governor FLORIDA FARM LABOR REGISTRATION AND TESTING WORKERS COMPENSATION INFORMATION Workers Compensation Coverage Provided by Contractor s Employer Name of Contractor/Corporation Social Security or License Number Street Rural Route or Post Office Box City State and Zip Code Effective this date I NAME ADDRESS AND PHONE NUMBER OF EMPLOYER will pay the premium for Workers Compensation Insurance on you and your crew members as long as you are in our employment. 488-6603 Fax 850. 487-9622 Ken Lawson Secretary Rick Scott Governor FLORIDA FARM LABOR REGISTRATION AND TESTING WORKERS COMPENSATION INFORMATION Workers Compensation Coverage Provided by Contractor s Employer Name of Contractor/Corporation Social Security or License Number Street Rural Route or Post Office Box City State and Zip Code Effective this date I NAME ADDRESS AND PHONE NUMBER OF EMPLOYER will pay the premium for Workers Compensation Insurance on you and your crew members as long as you are in our employment. I understand that this coverage will also be used to cover the transportation of workers. Our policy number is. Division of Regulation Jerry Wilson Director 1940 North Monroe Street Tallahassee FL 32399-2212 Phone 850. 488-6603 Fax 850. 487-9622 Ken Lawson Secretary Rick Scott Governor FLORIDA FARM LABOR REGISTRATION AND TESTING WORKERS COMPENSATION INFORMATION Workers Compensation Coverage Provided by Contractor s Employer Name of Contractor/Corporation Social Security or License Number Street Rural Route or Post Office Box City State and Zip Code Effective this date I NAME ADDRESS AND PHONE NUMBER OF EMPLOYER will pay the premium for Workers Compensation Insurance on you and your crew members as long as you are in our employment. I understand that this coverage will also be used to cover the transportation of workers. Our policy number is. .

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