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<br />C1t{ .ILI ~Y
<br />
<br />APPL:,CATION FOR
<br />FLORIDA
<br />WORKl:RS COMPENSATION INSURANCE
<br />111/, :tf,:p/lcltmn must /)6 tyfl.~.'1 !" prInted anti IIkM. III d!lplCSttl.. ~It/I.'
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<br />FOI Divl,'o" U.. O"'y
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<br />.rreouvI 0"'1:
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<br />Importllnt: In,lrl/cUen" Ie, ealrtple""sr "". 'Pl'licllllion elln !", fnll..... In tho Floridll WOfklf~-C~m"n'o".n In,qr.ncI PICII1-lnle'm"U'n "nil
<br />Proefldurtt_tf..nllb..... Thh,I,."dbeelr Ie .vell,b'e Irorn NCCI-O,rler "rolleul"l) e "0 p"k "I Comm"iSl Orlv.. II.., AlltCln, ilL n"'7.
<br />"'I"', ''''I''e' 11'1 ctll"~i,,(,.~ 8nrl 'eqUQIltDd 11l!o,",eliolll"Q,nug",y. Omi~oienll mllY ""lIlt In d6l.y of COy",,;..
<br />Th. ""dllllf~nld .mplay.r hlrlby IDDlI", lor W'Orktr. eO'T1ron~lll;,," i""u'.nce I" Flo,ide,nd ,)(p,.n!lly 'Oprolont. lh.. ,uC!h Inturlnal " tought 'n g""d ',,"h.
<br />This epplietlli.,,, d"olJ "nl p,o...ida OOVII.,..
<br />
<br />I. GENERAL INFOAMA TION
<br />I'll NAM& :OF'.EMP~6''t!A ',.'.::'
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<br />Previously Faxed a
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<br />. ESTIMAT/iD'
<br />AIiVEHUI
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<br />dU<.-::co
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<br />t W,\l\t~G ACORESS
<br />4. PRINelFAL LOCATION 2 ~ -
<br />S. OTHeR FLORIDA LOCA TlONS If'DW-,.
<br />
<br />~~OLL OFFice AODF.E9S ::..>
<br />
<br />Zip
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<br />l_OAl ST ^ TUS \f Sol. ''''"''.'0;.'0 "".O"h'. 0 CO,"O,"IIo. 0 'Othor (O,.'o'n): ~
<br />
<br />I, 'he Oppl~'nl Ie.nhy '.....d Ih'ough common mono.o"'onl Of Own.. ship 10 .ny enlhy nolllsto~",., WO.lh., co,,,... 18 raqu.".. ~ 8J
<br />ornol1 OYu"'O'No. ~..'.\.'.", ....:;~... .,~ ~..
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<br />You must ltrtlloh a r.opy 01 your most rp.cently lil"d Ins larm 94 t (Er11pl~yer' Quarterly r-9deral Tax ~turn, or any equlv<tlent $111le. or
<br />fedn.r<tI.reqUlrod current verifiable peyroll record (e.g" IRS 9.tO.941 E, 942 or 943 or stale unemployment W8ge report). If no such rllcord
<br />Is 8t1achod. oxplaIO:.,' .'1', \. .
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<br />, l<a, Ih". boo. a nam. ohon.. "'. OO''''''d''"o. m.rg" or olh" owno"hlp Chan.. dUllng Ih. """ Ih,.. ye...? 0 V.. ~
<br />II Y's, glv. .",lou. nom. _Old dale., oh.ng. "'d conleo1lh. NCCI-AII.nllo Owl".n ,"u1.n EAM.14: _ ~
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<br />Aro thflrn uperallons In states other than ~ioridtl? 0 Yes 9. If yos. you must list those stales and give langth ", lime In business
<br />by ~ate:
<br />
<br />"
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<br />Are ~ou requesting coverage 'or any 0' 1l1ose stales? 0 Yes @~ If yes. you must Iis1tho5lJ stat"s:
<br />
<br />r ____..I.
<br />
<br />.,.... nolt: Cove...1 In .ddillonll ""ies" 'ubi'CIIO Fl"d Oll~, and carri.. 'e"ew 10ld Ipproval. Coverage may.nOI be ..allabl. In
<br />some stlltes.
<br />
<br />~GEN;~tJi.P s'MFJPN>>ft~GENCY
<br />1CY Naml) ..l.837 7TH STREET .
<br />DADE CITY. FLORIDA 335Zb
<br />~S9_ (9114) M7-5454
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<br />Fax No.
<br />11 U CL1 ~l( ~I
<br />"hone No, _:J 6 . '-JoD . v v..."
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