Flrt Form 3100A PDF Details

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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

When using the online PDF tool by FormsPal, you are able to complete or change 1940 here. Our team is focused on giving you the ideal experience with our tool by consistently introducing new features and improvements. With these improvements, using our editor becomes easier than ever before! This is what you would have to do to begin:

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Step 2: This tool will allow you to customize most PDF forms in many different ways. Enhance it by writing personalized text, correct existing content, and put in a signature - all at your convenience!

To be able to finalize this PDF document, make sure that you type in the right details in each and every blank:

1. It is advisable to fill out the 1940 accurately, hence pay close attention when filling out the parts comprising these blanks:

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

It is easy to make errors while filling in your Office Address, so be sure to reread it before you'll submit it.

Step 3: Before moving on, make certain that all blank fields have been filled in the right way. When you determine that it is correct, click “Done." After getting afree trial account at FormsPal, you'll be able to download 1940 or email it directly. The file will also be easily accessible from your personal account menu with your changes. Here at FormsPal.com, we do our utmost to make sure that all your information is maintained secure.