Flrt Form 3100A PDF Details

Navigating the landscape of workers' compensation within the agricultural sector in Florida necessitates a firm understanding of the FLRT Form 3100A. This essential document, overseen by the Division of Regulation under the direction of Jerry Wilson and with the backing of key state officials including Secretary Ken Lawson and Governor Rick Scott, serves a critical function. It provides a formal record confirming that a farm labor contractor has secured the required workers' compensation coverage. Detailing the name and contact information of the contractor or corporation, alongside the insurance company and the local representative, ensures transparency and accountability. Furthermore, it is imperative for the insurance carrier or their authorized agent to certify that the policy not only exists but specifically covers the transportation of workers, augmenting the form's significance in safeguarding the well-being of agricultural employees. With spaces allocated for the meticulous recording of policy numbers, effective dates, and necessary contact details, the FLRT Form 3100A bridges a crucial link between farm labor contractors and the regulatory framework within which they operate.

QuestionAnswer
Form NameFlrt Form 3100A
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names3100A, DULY, FLRT, Lawson

Form Preview Example

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 Carried By Contractor Listed Below)

___________________________________

_________________________________

Name of Contractor/Corporation

Social Security or License Number

 

 

 

 

___________________________________

_________________________________

Insurance Company Name

Local Insurance Representative

 

___________________________________

_________________________________

Home Office Address

Office Address

 

___________________________________

_________________________________

City, State and Zip Code

City, State and Zip Code

 

(_______)___________________________

(_______)_________________________

Telephone Number

Telephone Number

 

___________________________________

Effective:_________________________

Workers' Compensation Policy Number

From

To

TO BE COMPLETED BY THE INSURANCE CARRIER OR CARRIER'S DULY AUTHORIZED AGENT

I HEREBY CERTIFY THAT THE ABOVE POLICY IS IN EFFECT, HAS BEEN ISSUED TO THE ABOVE NAMED APPLICANT, AND THAT THE POLICY COVERS THE TRANSPORTATION OF WORKERS.

__________________________________

_________________________________

Signature of Insurance Representative

Date

FLRT Form 3100A (Rev. 7.10)

How to Edit Flrt Form 3100A Online for Free

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The best ways to prepare CERTIFY portion 1

2. Now that the previous array of fields is finished, you should put in the necessary particulars in Insurance Company Name Home, Office Address, City State and Zip Code, Telephone Number, Effective, From, TO BE COMPLETED BY THE INSURANCE, I HEREBY CERTIFY THAT THE ABOVE, and Date so that you can move on further.

Office Address, From, and Effective of CERTIFY

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